Methods of using activin receptor type iia variants

ABSTRACT

The invention features polypeptides that include an extracellular ActRIIA variant. In some embodiments, a polypeptide of the invention includes an extracellular ActRIIA variant fused to an Fc domain monomer or moiety. The invention also features pharmaceutical compositions containing said polypeptides and methods of using the polypeptides to treat diseases and conditions including neuromuscular diseases, osteogenesis imperfecta, myelofibrosis, thrombocytopenia, neutropenia, and age-related and treatment-related metabolic disease.

SEQUENCE LISTING

The instant application contains a Sequence Listing which has been submitted electronically in XML file format and is hereby incorporated by reference in its entirety. Said XML copy, created on Oct. 26, 2022, is named 51184-016007_Sequence_Listing_10_26_22 and is 222,766 bytes in size.

BACKGROUND OF THE INVENTION

Thrombocytopenia is a condition characterized by abnormally low levels of platelets, also called thrombocytes, in the blood, and occurs when the bone marrow makes too few platelets or when too many platelets are destroyed or accumulate within an enlarged spleen. Patients with thrombocytopenia may experience internal or external bleeding, bleeding under the skin, and/or bruising. Treatment for thrombocytopenia depends on its cause and severity and is primarily focused on preventing death or disability caused by bleeding. Certain types of thrombocytopenia (e.g., immune thrombocytopenia) may be treated using corticosteroids, but other types of thrombocytopenia may require splenectomy or platelet transfusion.

Neutropenia is a condition characterized by an abnormally low number of neutrophils in the blood. Neutrophils typically constitute 45% to 75% of all white blood cells in the bloodstream and serve as the primary defense against infections. Reduced numbers of neutrophils can lead to difficulty in controlling infections and increase the risk of dying from an infection. In patients with severe neutropenia, infections can rapidly become severe or fatal. Antibiotics are used treat infection in patients having neutropenia, but treatments for neutropenia itself are limited, and primarily involve the use of growth factors, such as colony stimulating factors, to stimulate the production of white blood cells. Blood transfusions have not proven effective.

Myelodysplastic syndromes, or MDS, is a collection of bone marrow disorders characterized by ineffective hematopoiesis, often with a dramatic expansion of progenitor cells that are unable to mature into functioning blood cells. In the United States, there are 60,000 to 170,000 patients with MDS and 15,000 to 20,000 new cases of MDS reported each year. MDS predominantly affects older adults, with approximately 75% of patients aged 60 years or older at diagnosis. Median survival ranges from approximately nine years for very low-risk patients to less than a year for high-risk patients. Anemia is the most frequent consequence of ineffective hematopoiesis in patients with MDS due to low red blood cell production, and impacts 90% of MDS patients. Another consequence is thrombocytopenia. Patients with MDS-associated anemia are generally treated with red blood cell transfusions and erythropoiesis stimulating agents (ESAs), which are not approved for such treatment. MDS-associated thrombocytopenia is treated with platelet transfusions and platelet-stimulating agents.

Myelofibrosis is an uncommon type of bone marrow cancer that disrupts the normal production of blood cells. It can cause extensive scarring in the bone marrow, leading to severe anemia and a low number of platelets. Symptoms of myelofibrosis include fatigue, bone pain, easy bruising, easy bleeding, and fever. Patients with aggressive or high-risk myelofibrosis may require a blood transfusion or bone marrow transplant. Other treatment options include therapies that have known risks, such as androgen therapy and treatment with thalidomide or related medications. For patients with intermediate-risk myelofibrosis, treatment is typically directed at symptom management.

Osteogenesis imperfecta, also known as brittle bone disease, is a group of genetic disorders that mainly affect the bones. People with this condition have bones that break (fracture) easily, often from mild trauma or with no apparent cause. Multiple fractures are common, and in severe cases, can occur even before birth. Milder cases may involve only a few fractures over a person's lifetime. There are at least 19 recognized forms of osteogenesis imperfecta, designated type I through type XIX, with type I being the least severe and type II the most severe. Mild forms of osteogenesis imperfecta, such as type I, are characterized by bone fractures during childhood and adolescence that often result from minor trauma, such as falling while learning to walk. Fractures occur less frequently in adulthood. More severe types of osteogenesis imperfecta can feature frequent bone fractures that are present at birth and result from little or no trauma, in addition to short stature, curvature of the spine (scoliosis), joint deformities (contractures), hearing loss, respiratory problems, and a disorder of tooth development called dentinogenesis imperfecta. Mobility can be reduced in affected individuals, and some may use a walker or wheelchair. There is no cure for osteogenesis imperfecta, and treatment may include care of broken bones, pain medication, physical therapy, braces or wheelchairs, and surgery.

Neuromuscular diseases are a broadly defined group of disorders that impair the functioning of the muscles and may involve injury or dysfunction of peripheral nerves or muscle. The site of injury can be in the cell bodies (e.g., amyotrophic lateral sclerosis (ALS) or sensory ganglionopathies), axons (e.g., axonal peripheral neuropathies or brachial plexopathies), Schwann cells (e.g., chronic inflammatory demyelinating polyradiculoneuropathy), neuromuscular junction (e.g., myasthenia gravis or Lambert-Eaton myasthenic syndrome), muscle (e.g., inflammatory myopathy or muscular dystrophy), or any combination of these sites. Some neuromuscular diseases are also associated with central nervous system disease, such as ALS, but most are restricted to the peripheral nervous system. Neuromuscular diseases may feature muscle weakness, muscle atrophy, muscle pain, fasciculations, numbness, and/or paresthesia. There is no cure for most neuromuscular diseases, but some can be managed and treated using immunosuppressive drugs. Anticonvulsants and antidepressants may be used to treat pain associated with neuromuscular diseases.

There exists a need for novel and effective treatments for thrombocytopenia, neutropenia, myelofibrosis, osteogenesis imperfecta, and neuromuscular diseases.

SUMMARY OF THE INVENTION

The present invention features polypeptides that include an extracellular activin receptor type IIA (ActRIIA) variant. In some embodiments, a polypeptide of the invention includes an extracellular ActRIIA variant fused to the N- or C-terminus of an Fc domain monomer or moiety. Such moieties may be attached by amino acid or other covalent bonds and may increase stability of the polypeptide. A polypeptide including an extracellular ActRIIA variant fused to an Fc domain monomer may also form a dimer (e.g., a homodimer or heterodimer) through the interaction between two Fc domain monomers. The polypeptides of the invention may be used to increase lean mass, muscle mass, and/or strength in a subject having or at risk of developing a disease or condition involving weakness or atrophy of muscles, e.g., a neuromuscular disease, cachexia, disuse atrophy, treatment-related muscle loss or atrophy, hypotonia, hypoxia, or muscle loss or atrophy associated with a burn. The polypeptides of the invention may also be used to increase bone mass or bone mineral density in a subject having or at risk of developing osteogenesis imperfecta, neuromuscular disease-related bone loss, burn-induced bone loss, or anorexia-related bone loss. Additionally, the polypeptides of the invention may be used to increase red blood cell levels (e.g., increase hemoglobin levels, increase hematocrit, and/or increase red blood cell count), promote or increase the maturation and/or differentiation of erythroid progenitors, increase late-stage erythroid precursor maturation, or recruit early-stage progenitors into the erythroid lineage in a subject having or at risk of developing myelofibrosis or a myelodysplastic syndrome, to increase platelet levels (e.g., increase platelet count) in a subject in need thereof, e.g., a subject having or at risk of developing thrombocytopenia, or to increase neutrophil levels (e.g., increase neutrophil count) in a subject in need thereof, e.g., a subject having or at risk of developing neutropenia. The polypeptides of the invention may also be used to reduce body weight, reduce body fat, increase glucose clearance, increase insulin sensitivity, or reduce fasting insulin levels in a subject having or at risk of developing age-related or treatment-related metabolic disease. Further, the polypeptides of the invention may also be used to affect myostatin, activin (activin A and/or activin B), and/or bone morphogenetic protein 9 (BMP9) signaling in a subject having a risk of developing or having a disease or condition described herein.

Exemplary embodiments of the invention are described in the enumerated paragraphs below.

-   E1. A method of increasing platelet levels in a subject in need     thereof by administering to the subject a therapeutically effective     amount of a polypeptide, nucleic acid molecule, vector, or     pharmaceutical composition of Table 4. -   E2. A method of increasing platelet count in a subject in need     thereof by administering to the subject a therapeutically effective     amount of a polypeptide, nucleic acid molecule, vector, or     pharmaceutical composition of Table 4. -   E3. A method of promoting or increasing platelet production in a     subject in need thereof by administering to the subject a     therapeutically effective amount of a polypeptide, nucleic acid     molecule, vector, or pharmaceutical composition of Table 4. -   E4. A method of increasing or inducing megakaryocyte differentiation     and/or maturation in a subject in need thereof by administering to     the subject a therapeutically effective amount of a polypeptide,     nucleic acid molecule, vector, or pharmaceutical composition of     Table 4. -   E5. A method of reducing the accumulation of platelet progenitor     cells in a subject in need thereof by administering to the subject a     therapeutically effective amount of a polypeptide, nucleic acid     molecule, vector, or pharmaceutical composition of Table 4. -   E6. The method of any one of E1-E5, wherein the subject has or is at     risk of developing thrombocytopenia. -   E7. A method of affecting myostatin, activin A, activin B, and/or     BMP9 signaling (e.g., reducing or inhibiting the binding of     myostatin, activin A, activin B, and/or BMP9 to their endogenous     receptors) in a subject having or at risk of developing a disease or     condition involving low platelet levels by administering to the     subject a therapeutically effective amount of a polypeptide, nucleic     acid molecule, vector, or pharmaceutical composition of Table 4. -   E8. The method of E7, wherein the disease or condition is     thrombocytopenia. -   E9. A method of treating a subject having or at risk of developing     thrombocytopenia by administering to the subject a therapeutically     effective amount of a polypeptide, nucleic acid molecule, vector, or     pharmaceutical composition of Table 4. -   E10. A method of promoting platelet production by contacting a     megakaryocyte with a polypeptide, nucleic acid molecule, or vector     of Table 4 in an amount effective to promote platelet production. -   E11. The method of E10, wherein the contacting is in vitro. -   E12. A method of treating a subject having or at risk of developing     thrombocytopenia by administering to the subject a platelet produced     by the method of E10 or E11. -   E13. The method of any one of E6, E8, E9, and E12, wherein the     thrombocytopenia is or is associated with a bone marrow defect, a     myelodysplastic syndrome, bone marrow transplantation,     myelofibrosis, myelofibrosis treatment (e.g., treatment with a JAK     inhibitor, such as with ruxolitinib or fedratinib), ineffective     hematopoiesis, Gaucher disease, aplastic anemia, Fanconi anemia,     Diamond Blackfan anemia, Shwachman Diamond syndrome, heavy alcohol     consumption, cirrhosis of the liver, cancer (e.g., leukemia or     lymphoma), an autoimmune disease, a viral infection, a bacterial     infection, an enlarged spleen, a vitamin deficiency, cancer     treatment, thrombotic thrombocytopenic purpura, idiopathic     thrombocytopenic purpura, disseminated intravascular coagulation,     hemolytic uremic syndrome, paroxysmal nocturnal hemoglobinuria, a     reduction of platelets caused by medication (medication-induced     thrombocytopenia, e.g., thrombocytopenia caused by treatment with     heparin, quinine, sulfa-containing antibiotics, such as vancomycin,     rifampin, or trimethoprim, or anticonvulsants, such as phenytoin), a     dilution of platelets caused by a blood transfusion, hematopoietic     stem cell transplantation, acquired amegakaryocytic     thrombocytopenia, Pearson syndrome, dyskeratosis congenita, or     contraindication to transfusion. -   E14. The method of any one of E6, E8, E9, E12, and E13, wherein the     thrombocytopenia is associated with a myelodysplastic syndrome     (e.g., the subject has a myelodysplastic syndrome). -   E15. The method of any one of E6, E8, E9, E12, and E13, wherein the     thrombocytopenia is associated with myelofibrosis (e.g., the subject     has myelofibrosis). -   E16. The method of any one of E6, E8, E9, E12, and E13, wherein the     thrombocytopenia is associated with a bone marrow defect. -   E17. The method of any one of E6, E8, E9, E12, and E13, wherein the     thrombocytopenia is associated with bone marrow transplantation. -   E18. The method of any one of E6, E8, E9, E12, and E13, wherein the     thrombocytopenia is associated with cancer. -   E19. The method of any one of E6, E8, E9, E12, and E13, wherein the     thrombocytopenia is associated with cancer treatment (e.g.,     chemotherapy or radiation). -   E20. The method of any one of E6, E8, E9, E12, and E13, wherein the     thrombocytopenia is associated with hematopoietic stem cell     transplantation. -   E21. The method of any one of E6, E8, E9, E12, and E13, wherein the     thrombocytopenia is associated with an autoimmune disease. -   E22. The method of any one of E6, E8, E9, E12, and E13, wherein the     thrombocytopenia is associated with contraindication to transfusion. -   E23. The method of any one of E6, E8, E9, E12, and E13, wherein the     thrombocytopenia is associated with myelofibrosis treatment. -   E24. The method of any one of E6, E8, E9, E12, and E13, wherein the     thrombocytopenia is associated with ineffective hematopoiesis. -   E25. The method of any one of E6, E8, E9, and E12, wherein the     thrombocytopenia is familial thrombocytopenia. -   E26. The method of E25, wherein the familial thrombocytopenia is     May-Hegglin anomaly, Sebastian syndrome, Fechtner syndrome,     Epstein's syndrome, Wiskott-Aldrich syndrome, congenital     amegakaryocytic thrombocytopenia, platelet storage pool deficiency,     Hermansky-Pudlak syndrome, Bernard-Soulier syndrome, Von Willebrand     Disease Type 2B, ANKRD26-related thrombocytopenia, familial platelet     disorder with associated myeloid malignancy (FPD/AML),     thrombocytopenia associated with a mutation in Filamin-A,     thrombocytopenia absent radius syndrome, or thrombocytopenia     associated with a mutation in GATA1. -   E27. The method of any one of E6, E8, E9, and E12, wherein the     thrombocytopenia is immune thrombocytopenia. -   E28. The method of any one of E1-E27, wherein the method increases     platelet count, platelet production, and/or megakaryocyte     differentiation and/or maturation. -   E29. The method of any one of E1-E28, wherein the method reduces the     accumulation of platelet progenitor cells. -   E30. The method of any one of E1-E29, wherein the method improves     blood clotting, reduces bleeding events (e.g., reduces the incidence     of bleeding events), and/or reduces bleeding in the skin of the     subject. -   E31. The method of any one of E1-E10 and E12-E30, wherein the     subject is identified as having thrombocytopenia prior to     administration of the composition of Table 4 or the platelets     produced by the method of E10 or E11. -   E32. The method of any one of E1-E10 and E12-E30, wherein the method     further comprises identifying the subject as having thrombocytopenia     prior to administration of the composition of Table 4 or the     platelets produced by the method of E10 or E11. -   E33. The method of any one of E1-E10 and E12-E32, wherein the method     further comprises evaluating platelet levels after administration of     the composition of Table 4 or the platelets produced by the method     of E10 or E11. -   E34. A method of increasing neutrophil levels in a subject in need     thereof by administering to the subject a therapeutically effective     amount of a polypeptide, nucleic acid molecule, vector, or     pharmaceutical composition of Table 4. -   E35. A method of increasing neutrophil count in a subject in need     thereof by administering to the subject a therapeutically effective     amount of a polypeptide, nucleic acid molecule, vector, or     pharmaceutical composition of Table 4. -   E36. A method of promoting or increasing neutrophil production in a     subject in need thereof by administering to the subject a     therapeutically effective amount of a polypeptide, nucleic acid     molecule, vector, or pharmaceutical composition of Table 4. -   E37. A method of promoting or increasing the differentiation and/or     maturation of progenitor cells (e.g., myeloid progenitors,     myeloblasts, and/or myelocytes) into neutrophils in a subject in     need thereof by administering to the subject a therapeutically     effective amount of a polypeptide, nucleic acid molecule, vector, or     pharmaceutical composition of Table 4. -   E38. The method of any one of E34-E37, wherein the subject has or is     at risk of developing neutropenia. -   E39. A method of affecting myostatin, activin A, activin B, and/or     BMP9 signaling (e.g., reducing or inhibiting the binding of     myostatin, activin A, activin B, and/or BMP9 to their endogenous     receptors) in a subject having or at risk of developing a disease or     condition involving low neutrophil levels by administering to the     subject a therapeutically effective amount of a polypeptide, nucleic     acid molecule, vector, or pharmaceutical composition of Table 4. -   E40. The method of E39, wherein the disease or condition is     neutropenia. -   E41. A method of treating a subject having or at risk of developing     neutropenia by administering to the subject a therapeutically     effective amount of a polypeptide, nucleic acid molecule, vector, or     pharmaceutical composition of Table 4. -   E42. The method of any one of E38, E40, and E41, wherein the     neutropenia is associated with a bone marrow defect, a     myelodysplastic syndrome, bone marrow transplantation,     myelofibrosis, ineffective hematopoiesis, aplastic anemia, Fanconi     anemia, Diamond Blackfan anemia, Shwachman Diamond syndrome,     paroxysmal nocturnal hemoglobinuria, cancer (e.g., leukemia), a     vitamin deficiency, an enlarged spleen, an autoimmune disease, a     viral infection, a bacterial infection, cancer treatment, a     reduction in neutrophils caused by medication (e.g., medication used     to treat overactive thyroid, such as methimazole and     propylthiouracil; an antibiotic, such as vancomycin, penicillin G,     trimethoprim, and oxacillin; an antiviral drug, such as ganciclovir     and valganciclovir; an anti-inflammatory medication for ulcerative     colitis or rheumatoid arthritis, such as sulfasalazine; a drug used     to treat irregular heart rhythms, such as quinidine and     procainamide; an anticonvulsant, such as phenytoin and valproate; or     an antipsychotic, such as clozapine; or levamisole), inflammation,     hematopoietic stem cell transplantation, Pearson syndrome,     dyskeratosis congenita, or contraindication to transfusion. -   E43. The method of any one of E38 and E40-E42, wherein the     neutropenia is associated with a myelodysplastic syndrome (e.g., the     subject has a myelodysplastic syndrome). -   E44. The method of any one of E38 and E40-E42, wherein the     neutropenia is associated with myelofibrosis (e.g., the subject has     myelofibrosis). -   E45. The method of any one of E38 and E40-E42, wherein the     neutropenia is associated with a bone marrow defect. -   E46. The method of any one of E38 and E40-E42, wherein the     neutropenia is associated with bone marrow transplantation. -   E47. The method of any one of E38 and E40-E42, wherein the     neutropenia is associated with cancer. -   E48. The method of any one of E38 and E40-E42, wherein the     neutropenia is associated with cancer treatment (e.g., chemotherapy     or radiation). -   E49. The method of any one of E38 and E40-E42, wherein the     neutropenia is associated with hematopoietic stem cell     transplantation. -   E50. The method of any one of E38 and E40-E42, wherein the     neutropenia is associated with inflammation. -   E51. The method of any one of E38 and E40-E42, wherein the     neutropenia is associated with contraindication to transfusion. -   E52. The method of any one of E38 and E40-E42, wherein the     neutropenia is associated with ineffective hematopoiesis. -   E53. The method of any one of E38, E40, and E41, wherein the     neutropenia is chronic idiopathic neutropenia. -   E54. The method of any one of E38, E40, and E41, wherein the     neutropenia is familial neutropenia. -   E55. The method of E54, wherein the familial neutropenia is cyclic     neutropenia, chronic benign neutropenia, or severe congenital     neutropenia (SCN) (e.g., neutropenia associated with a mutation in     the gene ELANE (associated with SCN1), HAX1 (associated with SCN3),     G6PC3 (associated with SCN4), GFI1 (associated with SCN2), CSF3R,     WAS (associated with X-linked neutropenia/X-linked SCN), CXCR4,     VPS45A (associated with SCN5), or JAGN1). -   E56. The method of any one of E34-E55, wherein the method increases     neutrophil count, neutrophil production, and/or the differentiation     and/or maturation of progenitor cells into neutrophils. -   E57. The method of any one of E34-E56, wherein the method reduces     the subject's susceptibility to infection. -   E58. The method of any one of E34-E57, wherein the subject is     identified as having neutropenia prior to administration of the     composition of Table 4. -   E59. The method of any one of E34-E57, wherein the method further     comprises identifying the subject as having neutropenia prior to     administration of the composition of Table 4. -   E60. The method of any one of E34-E57, wherein the method further     comprises evaluating neutrophil levels after administration of the     composition of Table 4. -   E61. A method of increasing red blood cell levels (e.g., increasing     hemoglobin levels, red blood cell count, or hematocrit) in a subject     having or at risk of developing myelofibrosis, a myelodysplastic     syndrome, ineffective hematopoiesis, anemia associated with     myelofibrosis treatment, Pearson syndrome, dyskeratosis congenita,     congenital dyserythropoietic anemia, or congenital sideroblastic     anemia by administering to the subject a therapeutically effective     amount of a polypeptide, nucleic acid molecule, vector, or     pharmaceutical composition of Table 4. -   E62. A method of increasing red blood cell count in a subject having     or at risk of developing myelofibrosis, a myelodysplastic syndrome,     ineffective hematopoiesis, anemia associated with myelofibrosis     treatment, Pearson syndrome, dyskeratosis congenita, congenital     dyserythropoietic anemia, or congenital sideroblastic anemia by     administering to the subject a therapeutically effective amount of a     polypeptide, nucleic acid molecule, vector, or pharmaceutical     composition of Table 4. -   E63. A method of increasing hemoglobin levels in a subject having or     at risk of developing myelofibrosis, a myelodysplastic syndrome,     ineffective hematopoiesis, anemia associated with myelofibrosis     treatment, Pearson syndrome, dyskeratosis congenita, congenital     dyserythropoietic anemia, or congenital sideroblastic anemia by     administering to the subject a therapeutically effective amount of a     polypeptide, nucleic acid molecule, vector, or pharmaceutical     composition of Table 4. -   E64. A method of increasing hematocrit in a subject having or at     risk of developing myelofibrosis, a myelodysplastic syndrome,     ineffective hematopoiesis, anemia associated with myelofibrosis     treatment, Pearson syndrome, dyskeratosis congenita, congenital     dyserythropoietic anemia, or congenital sideroblastic anemia by     administering to the subject a therapeutically effective amount of a     polypeptide, nucleic acid molecule, vector, or pharmaceutical     composition of Table 4. -   E65. A method of promoting or increasing red blood cell production     in a subject having or at risk of developing myelofibrosis, a     myelodysplastic syndrome, ineffective hematopoiesis, anemia     associated with myelofibrosis treatment, Pearson syndrome,     dyskeratosis congenita, congenital dyserythropoietic anemia, or     congenital sideroblastic anemia by administering to the subject a     therapeutically effective amount of a polypeptide, nucleic acid     molecule, vector, or pharmaceutical composition of Table 4. -   E66. A method of affecting myostatin, activin A, activin B, and/or     BMP9 signaling (e.g., reducing or inhibiting the binding of     myostatin, activin A, activin B, and/or BMP9 to their endogenous     receptors) in a subject having or at risk of developing     myelofibrosis, a myelodysplastic syndrome, ineffective     hematopoiesis, anemia associated with myelofibrosis treatment,     Pearson syndrome, dyskeratosis congenita, congenital     dyserythropoietic anemia, or congenital sideroblastic anemia by     administering to the subject a therapeutically effective amount of a     polypeptide, nucleic acid molecule, vector, or pharmaceutical     composition of Table 4. -   E67. A method of promoting or increasing the maturation and/or     differentiation of erythroid progenitors (e.g., early-stage or late-     (e.g., terminal) stage erythroid progenitors, e.g., maturation     and/or differentiation of early stage erythroid progenitors, such as     colony forming unit-erythroid cells (CFU-Es) and burst forming     unit-erythroid cells (BFU-Es), into proerythroblasts, reticulocytes,     or red blood cells) in a subject having or at risk of developing     myelofibrosis, a myelodysplastic syndrome, ineffective     hematopoiesis, anemia associated with myelofibrosis treatment,     Pearson syndrome, dyskeratosis congenita, congenital     dyserythropoietic anemia, or congenital sideroblastic anemia by     administering to the subject a therapeutically effective amount of a     polypeptide, nucleic acid molecule, vector, or pharmaceutical     composition of Table 4. -   E68. A method of promoting or increasing proerythroblasts (e.g.,     proerythroblast numbers or proerythroblast count) in a subject     having or at risk of developing myelofibrosis, a myelodysplastic     syndrome, ineffective hematopoiesis, anemia associated with     myelofibrosis treatment, Pearson syndrome, dyskeratosis congenita,     congenital dyserythropoietic anemia, or congenital sideroblastic     anemia by administering to the subject a therapeutically effective     amount of a polypeptide, nucleic acid molecule, vector, or     pharmaceutical composition of Table 4. -   E69. A method of promoting or increasing reticulocytes (e.g.,     reticulocyte numbers or reticulocyte count) in a subject having or     at risk of developing myelofibrosis, a myelodysplastic syndrome,     ineffective hematopoiesis, anemia associated with myelofibrosis     treatment, Pearson syndrome, dyskeratosis congenita, congenital     dyserythropoietic anemia, or congenital sideroblastic anemia by     administering to the subject a therapeutically effective amount of a     polypeptide, nucleic acid molecule, vector, or pharmaceutical     composition of Table 4. -   E70. A method of promoting the recruitment of early-stage     progenitors into the erythroid lineage in a subject having or at     risk of developing myelofibrosis, a myelodysplastic syndrome,     ineffective hematopoiesis, anemia associated with myelofibrosis     treatment, Pearson syndrome, dyskeratosis congenita, congenital     dyserythropoietic anemia, or congenital sideroblastic anemia by     administering to the subject a therapeutically effective amount of a     polypeptide, nucleic acid molecule, vector, or pharmaceutical     composition of Table 4. -   E71. A method of promoting or increasing late-stage erythroid     precursor maturation (e.g., terminal maturation, such as the     maturation of reticulocytes into red blood cells or the maturation     of erythroblasts into reticulocytes and/or red blood cells) in a     subject having or at risk of developing myelofibrosis, a     myelodysplastic syndrome, ineffective hematopoiesis, anemia     associated with myelofibrosis treatment, Pearson syndrome,     dyskeratosis congenita, congenital dyserythropoietic anemia, or     congenital sideroblastic anemia by administering to the subject a     therapeutically effective amount of a polypeptide, nucleic acid     molecule, vector, or pharmaceutical composition of Table 4. -   E72. A method of reducing the accumulation of red blood cell     progenitor cells in a subject having or at risk of developing     myelofibrosis, a myelodysplastic syndrome, ineffective     hematopoiesis, anemia associated with myelofibrosis treatment,     Pearson syndrome, dyskeratosis congenita, congenital     dyserythropoietic anemia, or congenital sideroblastic anemia by     administering to the subject a therapeutically effective amount of a     polypeptide, nucleic acid molecule, vector, or pharmaceutical     composition of Table 4. -   E73. A method of increasing the number of early-stage erythroid     precursors and/or progenitors (e.g., expanding the early-stage     precursor and/or progenitor population) in a subject having or at     risk of developing myelofibrosis, a myelodysplastic syndrome,     ineffective hematopoiesis, anemia associated with myelofibrosis     treatment, Pearson syndrome, dyskeratosis congenita, congenital     dyserythropoietic anemia, or congenital sideroblastic anemia by     administering to the subject a therapeutically effective amount of a     polypeptide, nucleic acid molecule, vector, or pharmaceutical     composition of Table 4. -   E74. A method of promoting the progression of erythroid precursors     and/or progenitors through erythropoiesis in a subject having or at     risk of developing myelofibrosis, a myelodysplastic syndrome,     ineffective hematopoiesis, anemia associated with myelofibrosis     treatment, Pearson syndrome, dyskeratosis congenita, congenital     dyserythropoietic anemia, or congenital sideroblastic anemia by     administering to the subject a therapeutically effective amount of a     polypeptide, nucleic acid molecule, vector, or pharmaceutical     composition of Table 4. -   E75. A method of treating anemia in a subject having myelofibrosis,     a myelodysplastic syndrome, ineffective hematopoiesis, anemia     associated with myelofibrosis treatment, Pearson syndrome,     dyskeratosis congenita, congenital dyserythropoietic anemia, or     congenital sideroblastic anemia by administering to the subject a     therapeutically effective amount of a polypeptide, nucleic acid     molecule, vector, or pharmaceutical composition of Table 4. -   E76. The method of any one of E61-E75, wherein the subject has or is     at risk of developing a myelodysplastic syndrome (e.g., anemia     associated with a myelodysplastic syndrome). -   E77. The method of any one of E61-E75, wherein the subject has or is     at risk of developing myelofibrosis (e.g., anemia associated with     myelofibrosis). -   E78. The method of any one of E61-E75, wherein the subject has or is     at risk of developing anemia associated with myelofibrosis     treatment. -   E79. The method of any one of E13, E23, E61-E75 and E78, wherein the     myelofibrosis treatment is treatment with a JAK inhibitor (e.g.,     ruxolitinib or fedratinib). -   E80. The method of any one of E61-E75, wherein the subject has or is     at risk of developing Pearson syndrome. -   E81. The method of any one of E61-E75, wherein the subject has or is     at risk of developing dyskeratosis congenita. -   E82. The method of any one of E61-E75, wherein the subject has or is     at risk of developing congenital dyserythropoietic anemia. -   E83. The method of any one of E61-E75, wherein the subject has or is     at risk of developing congenital sideroblastic anemia. -   E84. The method of E83, wherein the congenital sideroblastic anemia     is associated with a mutation in ALAS2, SLC25A38, FECH, GLRX5,     HSPA9, HSCB, SLC25A38, or ABCB7. -   E85. The method of E83, wherein the congenital sideroblastic anemia     is associated with a mutation in PUS1, YARS2, LARS2, TRNT1, MT-ATP6,     NDUFB11, or SLC19A2, or with an mtDNA mutation. -   E86. The method of any one of E61-E85, wherein the subject has or is     at risk of developing ineffective hematopoiesis (e.g., ineffective     erythropoiesis). -   E87. The method of any one of E61-E86, wherein the method increases     red blood cell production, red blood cell count, hematocrit,     hemoglobin levels, erythrocyte progenitor differentiation and/or     maturation (e.g., of early and/or terminal stage erythroid     progenitors), late-stage erythroid precursor maturation, recruitment     of early-stage progenitors into the erythroid lineage,     proerythroblast numbers, early-stage erythroid precursor and/or     progenitor numbers (e.g., increases the early-stage precursor and/or     progenitor population), the progression of erythroid precursors     and/or progenitors through erythropoiesis, and/or reticulocyte     numbers. -   E88. The method of any one of E61-E87, wherein the method reduces     the accumulation of red blood cell progenitor cells. -   E89. A method of treating a subject having or at risk of developing     a myelodysplastic syndrome by administering to the subject a     therapeutically effective amount of a polypeptide, nucleic acid     molecule, vector, or pharmaceutical composition of Table 4. -   E90. A method of increasing platelet count, increasing platelet     production, increasing or inducing megakaryocyte differentiation     and/or maturation, reducing the accumulation of platelet progenitor     cells, increasing neutrophil count, increasing neutrophil     production, increasing or inducing the differentiation and/or     maturation of progenitor cells into neutrophils, improving blood     clotting, reducing bleeding events, reducing bleeding in the skin,     and/or reducing susceptibility to infection in a subject having or     at risk of developing a myelodysplastic syndrome by administering to     the subject a therapeutically effective amount of a polypeptide,     nucleic acid molecule, vector, or pharmaceutical composition of     Table 4. -   E91. The method of any one of E13, E14, E42, E43, E61-E75, E89, and     E90, wherein the myelodysplastic syndrome is myelodysplastic     syndrome with unilineage dysplasia (MDS-SLD), myelodysplastic     syndrome with multilineage dysplasia (MDS-MLD), myelodysplastic     syndrome with ring sideroblasts (MDS-RS, which includes single     lineage dysplasia (MDS-RS-SLD) and multilineage dysplasia     (MDS-RS-MLD)), myelodysplastic syndrome associated with isolated del     chromosome abnormality (myelodysplastic syndrome with isolated     del(5q)), myelodysplastic syndrome with excess blasts (e.g.,     myelodysplastic syndrome with excess blasts—type 1 (MDS-EB-1) or     myelodysplastic syndrome with excess blasts—type 2 (MDS-EB-2)),     myelodysplastic syndrome, unclassifiable (MDS-U), or myelodysplastic     syndrome/myeloproliferative neoplasm with ring sideroblasts and     thrombocytosis (MDS/MPN-RS-T). -   E92. The method of any one of E13, E14, E42, E43, E61-E75, and     E89-E91, wherein the myelodysplastic syndrome is MDS-SLD. -   E93. The method of any one of E13, E14, E42, E43, E61-E75, and     E89-E91, wherein the myelodysplastic syndrome is MDS-MLD. -   E94. The method of any one of E13, E14, E42, E43, E61-E75, and     E89-E91, wherein the myelodysplastic syndrome is MDS-RS-SLD. -   E95. The method of any one of E13, E14, E42, E43, E61-E75, and     E89-E91, wherein the myelodysplastic syndrome is MDS-RS-MLD. -   E96. The method of any one of E13, E14, E42, E43, E61-E75, and     E89-E91, wherein the myelodysplastic syndrome is myelodysplastic     syndrome with isolated del(5q). -   E97. The method of any one of E13, E14, E42, E43, E61-E75, and     E89-E91, wherein the myelodysplastic syndrome is MDS-EB-1. -   E98. The method of any one of E13, E14, E42, E43, E61-E75, and     E89-E91, wherein the myelodysplastic syndrome is MDS-EB-2. -   E99. The method of any one of E13, E14, E42, E43, E61-E75, and     E89-E91, wherein the myelodysplastic syndrome is MDS-U. -   E100. The method of any one of E13, E14, E42, E43, E61-E75, and     E89-E91, wherein the myelodysplastic syndrome is MDS/MPN-RS-T. -   E101. The method of any one of E13, E14, E42, E43, E61-E75, and     E89-E100, wherein the myelodysplastic syndrome is a ring sideroblast     positive myelodysplastic syndrome (RS positive MDS, e.g., the     subject has ring sideroblasts). -   E102. The method of E101, wherein the RS-positive myelodysplastic     syndrome is associated with a splicing factor mutation. -   E103. The method of E102, wherein the splicing factor mutation is a     mutation in Splicing Factor 3b Subunit 1 (SF3B1). -   E104. The method of any one of E13, E14, E42, E43, E61-E75, E89-E93,     and E96-E100, wherein the myelodysplastic syndrome is a non-ring     sideroblast myelodysplastic syndrome (non-RS, e.g., the subject     lacks ring sideroblasts). -   E105. The method of any one of E13, E14, E42, E43, E61-E75, and     E89-E104, wherein the myelodysplastic syndrome is a very low, low,     or intermediate risk myelodysplastic syndrome (e.g., as determined     by the Revised International Prognostic Scoring System). -   E106. The method of E105, wherein the myelodysplastic syndrome is a     very low risk myelodysplastic syndrome (e.g., as determined by the     Revised International Prognostic Scoring System). -   E107. The method of E105, wherein the myelodysplastic syndrome is a     low risk myelodysplastic syndrome (e.g., as determined by the     Revised International Prognostic Scoring System). -   E108. The method of E105, wherein the myelodysplastic syndrome is an     intermediate risk myelodysplastic syndrome (e.g., as determined by     the Revised International Prognostic Scoring System). -   E109. The method of any one of E13, E14, E42, E43, E61-E75, and     E89-E108, wherein the myelodysplastic syndrome is associated with a     defect in terminal maturation. -   E110. The method of any one of E13, E14, E42, E43, E61-E75, and     E89-E108, wherein the myelodysplastic syndrome is associated with a     defect in early-stage hematopoiesis (e.g., commitment or     differentiation of progenitor cells). -   E111. The method of any one of E13, E14, E42, E43, E61-E75, and     E89-E110, wherein the myelodysplastic syndrome is associated with     elevated endogenous erythropoietin levels. -   E112. The method of any one of E13, E14, E42, E43, E61-E75, and     E89-E111, wherein the myelodysplastic syndrome is associated with     hypocellular bone marrow (e.g., the subject has hypocellular bone     marrow). -   E113. A method of treating a subject having or at risk of developing     myelofibrosis by administering to the subject a therapeutically     effective amount of a polypeptide, nucleic acid molecule, vector, or     pharmaceutical composition of Table 4. -   E114. A method of increasing platelet count, increasing platelet     production, increasing or inducing megakaryocyte differentiation     and/or maturation, reducing the accumulation of platelet progenitor     cells, increasing neutrophil count, increasing neutrophil     production, increasing or inducing the differentiation and/or     maturation of progenitor cells into neutrophils, improving blood     clotting, reducing bleeding events, reducing bleeding in the skin,     and/or reducing susceptibility to infection in a subject having or     at risk of developing myelofibrosis by administering to the subject     a therapeutically effective amount of a polypeptide, nucleic acid     molecule, vector, or pharmaceutical composition of Table 4. -   E115. The method of any one of E1-E114, wherein the subject does not     respond well to treatment with erythropoietin (EPO), is susceptible     to the adverse effects of EPO, or does not respond well to treatment     with an erythroid maturation agent. -   E116. The method of any one of E1-E115, wherein the subject has     previously been treated with an erythropoiesis stimulating agent     (ESA). -   E117. The method of any one of E1-E115, wherein the subject has not     previously been treated with an erythropoiesis stimulating agent     (ESA). -   E118. The method of any one of E1-E117, wherein the subject has a     low transfusion burden. -   E119. The method of E118, wherein the subject has received 1-3 units     of RBCs (1-3 RBC transfusions) within eight weeks prior to starting     treatment with a polypeptide, nucleic acid molecule, vector, or     pharmaceutical composition of Table 4. -   E120. The method of E118, wherein the subject has received 0 units     of RBCs (0 RBC transfusions) within eight weeks prior to starting     treatment with a polypeptide, nucleic acid molecule, vector, or     pharmaceutical composition of Table 4. -   E121. The method of any one of E1-E117, wherein the subject has a     high transfusion burden. -   E122. The method of any one of E61-E121, wherein the method reduces     the subject's need for a blood transfusion (e.g., reduces     transfusion burden). -   E123. A method of increasing lean mass in a subject having or at     risk of developing a neuromuscular disease, cachexia, disuse     atrophy, treatment-related muscle loss or atrophy, hypotonia, muscle     loss or atrophy associated with hypoxia, or muscle loss or atrophy     associated with a burn injury by administering to the subject a     therapeutically effective amount of a polypeptide, nucleic acid     molecule, vector, or pharmaceutical composition of Table 4. -   E124. A method of increasing muscle mass in a subject having or at     risk of developing a neuromuscular disease, cachexia, disuse     atrophy, treatment-related muscle loss or atrophy, hypotonia, muscle     loss or atrophy associated with hypoxia, or muscle loss or atrophy     associated with a burn injury by administering to the subject a     therapeutically effective amount of a polypeptide, nucleic acid     molecule, vector, or pharmaceutical composition of Table 4. -   E125. A method of affecting myostatin, activin A, activin B, and/or     BMP9 signaling (e.g., reducing or inhibiting the binding of     myostatin, activin A, activin B, and/or BMP9 to their endogenous     receptors) in a subject having or at risk of developing a     neuromuscular disease, cachexia, disuse atrophy, treatment-related     muscle loss or atrophy, hypotonia, muscle loss or atrophy associated     with hypoxia, or muscle loss or atrophy associated with a burn     injury by administering to the subject a therapeutically effective     amount of a polypeptide, nucleic acid molecule, vector, or     pharmaceutical composition of Table 4. -   E126. The method of any one of E123-E125, wherein the subject has or     is at risk of developing a neuromuscular disease. -   E127. A method of treating a subject having or at risk of developing     a neuromuscular disease by administering to the subject a     therapeutically effective amount of a polypeptide, nucleic acid     molecule, vector, or pharmaceutical composition of Table 4. -   E128. The method of any one of E123-E125, wherein the subject has or     is at risk of developing disuse atrophy. -   E129. A method of treating a subject having or at risk of developing     disuse atrophy by administering to the subject a therapeutically     effective amount of a polypeptide, nucleic acid molecule, vector, or     pharmaceutical composition of Table 4. -   E130. The method of any one of E123-E125, wherein the subject has or     is at risk of developing treatment-related muscle loss or atrophy. -   E131. A method of treating a subject having or at risk of developing     treatment-related muscle loss or atrophy by administering to the     subject a therapeutically effective amount of a polypeptide, nucleic     acid molecule, vector, or pharmaceutical composition of Table 4. -   E132. The method of any one of E123-E125, E130, and E131, wherein     the treatment is glucocorticoid treatment, FGF-21 treatment, GLP-1     treatment, bariatric surgery (e.g., gastric bypass), cancer therapy,     or treatment for obesity or Type 2 diabetes. -   E133. The method of any one of E123-E125, wherein the subject has or     is at risk of developing hypotonia. -   E134. A method of treating a subject having or at risk of developing     hypotonia by administering to the subject a therapeutically     effective amount of a polypeptide, nucleic acid molecule, vector, or     pharmaceutical composition of Table 4. -   E134. The method of any one of E123-E125, wherein the subject has or     is at risk of developing muscle loss or atrophy associated with     hypoxia. -   E136. A method of treating a subject having or at risk of developing     muscle loss or atrophy associated with hypoxia by administering to     the subject a therapeutically effective amount of a polypeptide,     nucleic acid molecule, vector, or pharmaceutical composition of     Table 4. -   E137. The method of any one of E123-E125, wherein the subject has or     is at risk of developing muscle loss or atrophy associated with a     burn injury. -   E138. A method of treating a subject having or at risk of developing     muscle loss or atrophy associated with a burn injury by     administering to the subject a therapeutically effective amount of a     polypeptide, nucleic acid molecule, vector, or pharmaceutical     composition of Table 4. -   E139. The method of any one of E123-E125, wherein the subject has or     is at risk of developing cachexia. -   E140. The method of any one of E123-E125 and E139, wherein the     cachexia is HIV-related cachexia, cardiac cachexia, cachexia     associated with chronic kidney disease, or pulmonary cachexia. -   E141. A method of treating a subject having or at risk of developing     HIV-related cachexia, cardiac cachexia, cachexia associated with     chronic kidney disease, or pulmonary cachexia by administering to     the subject a therapeutically effective amount of a polypeptide,     nucleic acid molecule, vector, or pharmaceutical composition of     Table 4. -   E142. The method of any one of E123-E141, wherein the method     increases lean mass and/or muscle mass. -   E143. A method of increasing bone mineral density in a subject     having or at risk of developing osteogenesis imperfecta,     neuromuscular disease-related bone loss, burn-induced bone loss,     anorexia-related bone loss, bone loss associated with bariatric     surgery (e.g., gastric bypass), or bone loss associated with     androgen or estrogen deprivation therapy by administering to the     subject a therapeutically effective amount of a polypeptide, nucleic     acid molecule, vector, or pharmaceutical composition of Table 4. -   E144. A method of reducing bone resorption in a subject having or at     risk of developing osteogenesis imperfecta, neuromuscular     disease-related bone loss, burn-induced bone loss, anorexia-related     bone loss, bone loss associated with bariatric surgery, or bone loss     associated with androgen or estrogen deprivation therapy by     administering to the subject a therapeutically effective amount of a     polypeptide, nucleic acid molecule, vector, or pharmaceutical     composition of Table 4. -   E145. A method of increasing bone formation in a subject having or     at risk of developing osteogenesis imperfecta, neuromuscular     disease-related bone loss, burn-induced bone loss, anorexia-related     bone loss, bone loss associated with bariatric surgery, or bone loss     associated with androgen or estrogen deprivation therapy by     administering to the subject a therapeutically effective amount of a     polypeptide, nucleic acid molecule, vector, or pharmaceutical     composition of Table 4. -   E146. A method of increasing bone strength in a subject having or at     risk of developing osteogenesis imperfecta, neuromuscular     disease-related bone loss, burn-induced bone loss, anorexia-related     bone loss, bone loss associated with bariatric surgery, or bone loss     associated with androgen or estrogen deprivation therapy by     administering to the subject a therapeutically effective amount of a     polypeptide, nucleic acid molecule, vector, or pharmaceutical     composition of Table 4. -   E147. A method of reducing the risk or occurrence of bone fracture     in a subject having or at risk of developing osteogenesis     imperfecta, neuromuscular disease-related bone loss, burn-induced     bone loss, anorexia-related bone loss, bone loss associated with     bariatric surgery, or bone loss associated with androgen or estrogen     deprivation therapy by administering to the subject a     therapeutically effective amount of a polypeptide, nucleic acid     molecule, vector, or pharmaceutical composition of Table 4. -   E148. A method of affecting myostatin, activin A, activin B, and/or     BMP9 signaling (e.g., reducing or inhibiting the binding of     myostatin, activin A, activin B, and/or BMP9 to their endogenous     receptors) in a subject having or at risk of developing osteogenesis     imperfecta, neuromuscular disease-related bone loss, burn-induced     bone loss, anorexia-related bone loss, bone loss associated with     bariatric surgery, or bone loss associated with androgen or estrogen     deprivation therapy by administering to the subject a     therapeutically effective amount of a polypeptide, nucleic acid     molecule, vector, or pharmaceutical composition of Table 4. -   E149. The method of any one of E143-E148, wherein the subject has or     is at risk of developing osteogenesis imperfecta. -   E150. A method of treating a subject having or at risk of developing     osteogenesis imperfecta by administering to the subject a     therapeutically effective amount of a polypeptide, nucleic acid     molecule, vector, or pharmaceutical composition of Table 4. -   E151. The method of any one of E143-E148, wherein the subject has or     is at risk of developing bone loss associated with bariatric     surgery. -   E152. A method of treating a subject having or at risk of developing     bone loss associated with bariatric surgery by administering to the     subject a therapeutically effective amount of a polypeptide, nucleic     acid molecule, vector, or pharmaceutical composition of Table 4. -   E153. The method of any one of E143-E148, wherein the subject has or     is at risk of developing bone loss associated with androgen or     estrogen deprivation therapy. -   E154. A method of treating a subject having or at risk of developing     bone loss associated with androgen or estrogen deprivation therapy     by administering to the subject a therapeutically effective amount     of a polypeptide, nucleic acid molecule, vector, or pharmaceutical     composition of Table 4. -   E155. The method of any one of E143-E148, wherein the subject has or     is at risk of developing neuromuscular disease-related bone loss. -   E156. A method of treating a subject having or at risk of developing     neuromuscular disease-related bone loss by administering to the     subject a therapeutically effective amount of a polypeptide, nucleic     acid molecule, vector, or pharmaceutical composition of Table 4. -   E157. The method of any one of E123-E126, E143-E148, E155, and E156,     wherein the neuromuscular disease is a muscular dystrophy, autonomic     neuropathy, botulism, Charcot-Marie-Tooth disease (CMT), chronic     inflammatory demyelinating polyradiculoneuropathy, congenital     myasthenic syndrome, a congenital myopathy, cramp-fasciculation     syndrome, dermatomyositis, diabetic neuropathy, a distal myopathy, a     dystrophinopathy, an endocrine myopathy, a focal muscular atrophy,     glycogen storage disease type II, Guillain-Barre syndrome,     hereditary spastic paraplegia, Isaac's syndrome, Kearns-Sayre     syndrome, Kennedy disease, Lambert-Eaton myasthenic syndrome, a     metabolic myopathy, a metabolic neuropathy, a mitochondrial     myopathy, a motor neuron disease, multiple sclerosis, myasthenia     gravis, myotonic dystrophy, a necrotizing myopathy, neuromyotonia,     neuropathy of Friedreich's Ataxia, a nutritional neuropathy,     peripheral neuropathy, polymyositis, primary lateral sclerosis,     Schwartz-Jampel Syndrome, small fiber neuropathy, spinal and bulbar     muscular atrophy, spinal muscular atrophy (SMA), spinal muscular     atrophy with respiratory distress type 1, stiff person syndrome,     toxic neuropathy, or Troyer syndrome. -   E158. The method of E157, wherein the neuromuscular disease is a     muscular dystrophy. -   E159. The method of E158, wherein the muscular dystrophy is Becker     muscular dystrophy, myotonic dystrophy, congenital muscular     dystrophy, limb-girdle muscular dystrophy, distal muscular     dystrophy, oculopharyngeal muscular dystrophy, or Emery-Dreifuss     muscular dystrophy. -   E160. The method of E159, wherein the muscular dystrophy is a     congenital muscular dystrophy. -   E161. The method of E160, wherein the congenital muscular dystrophy     is congenital muscular dystrophy type 1A (MDC1A), congenital     muscular dystrophy type 1C, congenital muscular dystrophy type 1 D,     congenital muscular dystrophy type 1B, Fukuyama congenital muscular     dystrophy, muscle-eye-brain disease, Walker-Warburg Syndrome, rigid     spine muscular dystrophy, Ullrich congenital muscular dystrophy, or     muscular dystrophy associated with a mutation in integrin alpha 7,     integrin alpha 9, docking protein 7, laminin A/C, SECIS binding     protein 2, or choline kinase beta. -   E162. The method of E161, wherein the congenital muscular dystrophy     is MDC1A. -   E163. The method of E157, wherein the neuromuscular disease is CMT. -   E164. The method of E157, wherein the neuromuscular disease is SMA. -   E165. The method of any one of E143-E148, wherein the subject has or     is at risk of developing burn-induced bone loss. -   E166. A method of treating a subject having or at risk of developing     burn-induced bone loss by administering to the subject a     therapeutically effective amount of a polypeptide, nucleic acid     molecule, vector, or pharmaceutical composition of Table 4. -   E167. The method of any one of E143-E148, wherein the subject has or     is at risk of developing anorexia-related bone loss. -   E168. A method of treating a subject having or at risk of developing     anorexia-related bone loss by administering to the subject a     therapeutically effective amount of a polypeptide, nucleic acid     molecule, vector, or pharmaceutical composition of Table 4. -   E169. The method of any one of E143-E148, wherein the subject is at     risk of bone fracture. -   E170. The method of any one of E143-E169, wherein the method     increases bone formation in the subject. -   E171. The method of any one of E143-E170, wherein the method     decreases bone resorption in the subject. -   E172. The method of any one of E143-E171, wherein the method     increases osteoblast activity or osteoblastogenesis. -   E173. The method of any one of E143-E172, wherein the method     decreases osteoclast activity or decreases osteoclastogenesis. -   E174. The method of any one of E143-E173, wherein the method reduces     the risk or occurrence of bone fracture. -   E175. The method of any one of E143-E174, wherein the method     increases bone strength. -   E176. The method of any one of E143-E175, wherein the bone is     cortical bone. -   E177. The method of any one of E143-E175, wherein the bone is     trabecular bone. -   E178. A method of reducing body fat in a subject having or at risk     of developing treatment-related metabolic disease or age-related     metabolic disease by administering to the subject a therapeutically     effective amount of a polypeptide, nucleic acid molecule, vector, or     pharmaceutical composition of Table 4. -   E179. A method of reducing body weight in a subject having or at     risk of developing treatment-related metabolic disease or     age-related metabolic disease by administering to the subject a     therapeutically effective amount of a polypeptide, nucleic acid     molecule, vector, or pharmaceutical composition of Table 4. -   E180. A method of reducing blood glucose in a subject having or at     risk of developing treatment-related metabolic disease or     age-related metabolic disease by administering to the subject a     therapeutically effective amount of a polypeptide, nucleic acid     molecule, vector, or pharmaceutical composition of Table 4. -   E181. A method of increasing insulin sensitivity in a subject having     or at risk of developing treatment-related metabolic disease or     age-related metabolic disease by administering to the subject a     therapeutically effective amount of a polypeptide, nucleic acid     molecule, vector, or pharmaceutical composition of Table 4. -   E182. A method of affecting myostatin, activin A, activin B, and/or     BMP9 signaling (e.g., reducing or inhibiting the binding of     myostatin, activin A, activin B, and/or BMP9 to their endogenous     receptors) in a subject having or at risk of developing     treatment-related metabolic disease or age-related metabolic disease     by administering to the subject a therapeutically effective amount     of a polypeptide, nucleic acid molecule, vector, or pharmaceutical     composition of Table 4. -   E183. A method of treating and/or preventing treatment-related     metabolic disease or age-related metabolic disease in a subject by     administering to said subject a therapeutically effective amount of     a polypeptide, nucleic acid molecule, vector, or pharmaceutical     composition of Table 4. -   E184. The method of any one of E178-E183, wherein the     treatment-related metabolic disease is associated with treatment     with a glucocorticoid (e.g., a corticosteroid, such as prednisone),     a selective serotonin reuptake inhibitors (SSRI, e.g., paroxetine,     mirtazapine, fluoxetine, escitalopram, or sertraline), a     serotonin-norepinephrine reuptake inhibitors (SNRI), a tricyclic     antidepressant (e.g., amitriptyline), a mood stabilizer (e.g.,     valproic acid or lithium), an antipsychotic (e.g., olanzapine,     chlorpromazine, or clozapine), or a diabetes medication (e.g.,     insulin, chlorpropamide). -   E185. The method of any one of E178-E184, wherein the metabolic     disease is obesity, Type 1 diabetes, or Type 2 diabetes. -   E186. The method of E185, wherein the metabolic disease is obesity. -   E187. The method of E185, wherein the metabolic disease is Type 1     diabetes. -   E188. The method of E185, wherein the metabolic disease is Type 2     diabetes. -   E189. The method of any one of E178-E188, wherein the method reduces     body weight and/or percentage of body weight gain of said subject. -   E190. The method of any one of E178-E189, wherein the method reduces     amount of body fat and/or percentage of body fat of said subject. -   E191. The method of any one of E178-E190, wherein the method does     not affect the appetite for food intake of said subject. -   E192. The method of any one of E178-E191, wherein the method reduces     adiposity of said subject. -   E193. The method of any one of E178-E192, wherein the method reduces     the weights of epididymal and perirenal fat pads of said subject. -   E194. The method of any one of E178-E193, wherein the method reduces     the amount of subcutaneous, visceral, and/or hepatic fat of said     subject. -   E195. The method of any one of E178-E194, wherein the method lowers     the level of fasting insulin of said subject. -   E196. The method of any one of E178-E195, wherein the method lowers     the level of blood glucose of said subject. -   E197. The method of any one of E178-E196, wherein the method     increases insulin sensitivity of said subject. -   E198. The method of any one of E178-E197, wherein the method     increases the rate of glucose clearance of said subject. -   E199. The method of any one of E178-E198, wherein the method     improves the serum lipid profile of said subject. -   E200. The method of any one of E178-E199, wherein the method delays,     reduces, or eliminates the need for insulin treatment. -   E201. The method of any one of E178-E200, wherein the method does     not reduce lean mass. -   E202. The method of any one of E1-E201, wherein the method reduces     or inhibits the binding of activin A, activin B, and/or myostatin to     their receptors (e.g., their endogenous receptors). -   E203. The method of any one of E1-E33, E89-E122, and E202, wherein     the composition is administered in an amount sufficient to increase     platelet levels, increase platelet production, increase platelet     count, increase or induce megakaryocyte differentiation and/or     maturation, reduce the accumulation of platelet progenitor cells,     improve blood clotting, reduce bleeding events, reduce bleeding in     the skin, treat thrombocytopenia, affect myostatin, activin A,     activin B, and/or BMP9 signaling in the subject, or reduce or     inhibit the binding of activin A, activin B, and/or myostatin to     their receptors. -   E204. The method of any one of E34-E60, E89-E122, and E202, wherein     the composition is administered in an amount sufficient to increase     neutrophil levels, increase neutrophil production, increase     neutrophil count, increase or induce the differentiation and/or     maturation of progenitor cells into neutrophils, treat neutropenia,     reduce susceptibility to infection, affect myostatin, activin A,     activin B, and/or BMP9 signaling in the subject, or reduce or     inhibit the binding of activin A, activin B, and/or myostatin to     their receptors. -   E205. The method of any one of E61-E122 and E202, wherein the     composition is administered in an amount sufficient to increase red     blood cell levels, increase hemoglobin levels, increase red blood     cell production, increase red blood cell count, increase hematocrit,     reduce the need for a blood transfusion, increase the maturation     and/or differentiation of erythroid progenitors (e.g., early and/or     terminal stage erythroid progenitors), increase late-stage erythroid     precursor maturation, recruit early-stage progenitors into the     erythroid lineage, increase reticulocytes, increase proerythroblast     numbers, reduce the accumulation of red blood cell progenitor cells,     increase the number of early-stage erythroid precursors and/or     progenitors, promote the progression of erythroid precursors and/or     progenitors through erythropoiesis, treat anemia, affect myostatin,     activin A, activin B, and/or BMP9 signaling in the subject, or     reduce or inhibit the binding of activin A, activin B, and/or     myostatin to their receptors. -   E206. The method of any one of E123-E142, E157-E164, and E202,     wherein the composition is administered in an amount sufficient to     increase muscle mass and/or strength, increase lean mass, affect     myostatin, activin A, activin B, and/or BMP9 signaling in the     subject, or reduce or inhibit the binding of activin A, activin B,     and/or myostatin to their receptors. -   E207. The method of any one of E143-E177 and E202, wherein the     composition is administered in an amount sufficient to increase     mineral bone density, reduce bone resorption, reduce the rate of     bone resorption, increase bone formation, increase the rate of bone     formation, reduce osteoclast activity, increase osteoblast activity,     increase bone strength, reduce the risk or occurrence of bone     fracture, affect myostatin, activin A, activin B, and/or BMP9     signaling in the subject, or reduce or inhibit the binding of     activin A, activin B, and/or myostatin to their receptors. -   E208. The method of any one of E178-E202, wherein the composition is     administered in an amount sufficient to reduce body fat, reduce the     amount of subcutaneous fat, reduce the amount of visceral and/or     hepatic fat, reduce adiposity, reduce the weights of epididymal and     perirenal fat pads, reduce body fat percentage, reduce body weight,     reduce the percentage of body weight gain, reduce fasting insulin     levels, reduce blood glucose levels, increase insulin sensitivity,     affect myostatin, activin A, activin B, and/or BMP9 signaling in the     subject, reduce the proliferation of adipose cells, reduce or     inhibit the binding of activin A, activin B, and/or myostatin to     their receptors, reduce LDL, reduce triglycerides, improve the serum     lipid profile, regulate insulin biosynthesis and/or secretion from     β-cells, delay, postpone, or reduce the need for insulin, or     increase glucose clearance. -   E209. The method of any one of E1-E208, wherein the method does not     cause a vascular complication in the subject. -   E210. The method of E209, wherein the method does not increase     vascular permeability or leakage. -   E211. The method of any one of E1-E210, wherein the subject is a     human.

Definitions

To facilitate the understanding of this invention, a number of terms are defined below. Terms defined herein have meanings as commonly understood by a person of ordinary skill in the areas relevant to the invention. Terms such as “a”, “an,” and “the” are not intended to refer to only a singular entity but include the general class of which a specific example may be used for illustration. The terminology herein is used to describe specific embodiments of the invention, but their usage does not limit the invention, except as outlined in the claims.

As used herein, the term “about” refers to a value that is within 10% above or below the value being described.

As used herein, any values provided in a range of values include both the upper and lower bounds, and any values contained within the upper and lower bounds.

As used herein, the term “extracellular activin receptor type IIA (ActRIIA) variant” refers to a peptide including a soluble, extracellular portion of the single transmembrane receptor, ActRIIA, that has at least one amino acid substitution relative to a wild-type extracellular ActRIIA (e.g., bold portion of the sequence of SEQ ID NO: 75 shown below) or an extracellular ActRIIA having any one of the sequences of SEQ ID NOs: 76-96. The sequence of the wild-type, human ActRIIA precursor protein is shown below (SEQ ID NO: 75), in which the signal peptide is italicized and the extracellular portion is bold.

Wild-type, human ActRIIA precursor protein  (SEQ ID NO: 75): MGAAAKLAFAVFLISCSS GAILGRSETQECLFFNANWEKDRT NQTGVEPCYGDKDKRRHCFATWKNISGSIEIVKQGCWLDDIN CYDRTDCVEKKDSPEVYFCCCEGNMCNEKFSYFPEMEVTQPT SNPVTPKPPYYNILLYSLVPLMLIAGIVICAFWVYRHHKMAY PPVLVPTQDPGPPPPSPLLGLKPLQLLEVKARGRFGCVWKAQ LLNEYVAVKIFPIQDKQSWQNEYEVYSLPGMKHENILQFIGA EKRGTSVDVDLWLITAFHEKGSLSDFLKANVVSWNELCHIAE TMARGLAYLHEDIPGLKDGHKPAISHRDIKSKNVLLKNNLTA CIADFGLALKFEAGKSAGDTHGQVGTRRYMAPEVLEGAINFQ RDAFLRIDMYAMGLVLWELASRCTAADGPVDEYMLPFEEEIG QHPSLEDMQEVVVHHKKRPVLRDYWQKHAGMAMLCETIEECW DHDAEARLSAGCVGERITQMQRLTNIITTEDIVTVVTMVTNV DFPPKESSL

An extracellular ActRIIA variant may have a sequence of any one of SEQ ID NOs: 1-72. In particular embodiments, an extracellular ActRIIA variant has a sequence of any one of SEQ ID NOs: 6-72 (Table 2). In some embodiments, an extracellular ActRIIA variant may have at least 85% (e.g., at least 85%, 87%, 90%, 92%, 95%, 97%, or greater) amino acid sequence identity to the sequence of a wild-type extracellular ActRIIA (SEQ ID NO: 73).

As used herein, the term “linker” refers to a linkage between two elements, e.g., peptides or protein domains. A polypeptide described herein may include an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having a sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) fused to a moiety. The moiety may increase stability or improve pharmacokinetic properties of the polypeptide. The moiety (e.g., Fc domain monomer, a wild-type Fc domain, an Fc domain with amino acid substitutions (e.g., one or more substitutions that reduce dimerization), an albumin-binding peptide, a fibronectin domain, or a human serum albumin) may be fused to the polypeptide by way of a linker. A linker can be a covalent bond or a spacer. The term “bond” refers to a chemical bond, e.g., an amide bond or a disulfide bond, or any kind of bond created from a chemical reaction, e.g., chemical conjugation. The term “spacer” refers to a moiety (e.g., a polyethylene glycol (PEG) polymer) or an amino acid sequence (e.g., a 1-200 amino acid sequence) occurring between two elements, e.g., peptides or protein domains, to provide space and/or flexibility between the two elements. An amino acid spacer is part of the primary sequence of a polypeptide (e.g., fused to the spaced peptides via the polypeptide backbone). The formation of disulfide bonds, e.g., between two hinge regions that form an Fc domain, is not considered a linker.

As used herein, the term “Fc domain” refers to a dimer of two Fc domain monomers. An Fc domain has at least 80% sequence identity (e.g., at least 85%, 90%, 95%, 97%, or 100% sequence identity) to a human Fc domain that includes at least a C_(H)2 domain and a C_(H)3 domain. An Fc domain monomer includes second and third antibody constant domains (C_(H)2 and C_(H)3). In some embodiments, the Fc domain monomer also includes a hinge domain. An Fc domain does not include any portion of an immunoglobulin that is capable of acting as an antigen-recognition region, e.g., a variable domain or a complementarity determining region (CDR). In the wild-type Fc domain, the two Fc domain monomers dimerize by the interaction between the two C_(H)3 antibody constant domains, as well as one or more disulfide bonds that form between the hinge domains of the two dimerizing Fc domain monomers. In some embodiments, an Fc domain may be mutated to lack effector functions, typical of a “dead Fc domain.” In certain embodiments, each of the Fc domain monomers in an Fc domain includes amino acid substitutions in the C_(H)2 antibody constant domain to reduce the interaction or binding between the Fc domain and an Fcγ receptor. In some embodiments, the Fc domain contains one or more amino acid substitutions that reduce or inhibit Fc domain dimerization. An Fc domain can be any immunoglobulin antibody isotype, including IgG, IgE, IgM, IgA, or IgD. Additionally, an Fc domain can be an IgG subtype (e.g., IgG1, IgG2a, IgG2b, IgG3, or IgG4). The Fc domain can also be a non-naturally occurring Fc domain, e.g., a recombinant Fc domain.

As used herein, the term “albumin-binding peptide” refers to an amino acid sequence of 12 to 16 amino acids that has affinity for and functions to bind serum albumin. An albumin-binding peptide can be of different origins, e.g., human, mouse, or rat. In some embodiments, an albumin-binding peptide has the sequence DICLPRWGCLW (SEQ ID NO: 151).

As used herein, the term “fibronectin domain” refers to a high molecular weight glycoprotein of the extracellular matrix, or a fragment thereof, that binds to, e.g., membrane-spanning receptor proteins such as integrins and extracellular matrix components such as collagens and fibrins. In some embodiments, a fibronectin domain is a fibronectin type III domain (SEQ ID NO: 152) having amino acids 610-702 of the sequence of UniProt ID NO: P02751. In other embodiments, a fibronectin domain is an adnectin protein.

As used herein, the term “human serum albumin” refers to the albumin protein present in human blood plasma. Human serum albumin is the most abundant protein in the blood. It constitutes about half of the blood serum protein. In some embodiments, a human serum albumin has the sequence of UniProt ID NO: P02768 (SEQ ID NO: 153).

As used herein, the term “endogenous” describes a molecule (e.g., a polypeptide, nucleic acid, or cofactor) that is found naturally in a particular organism (e.g., a human) or in a particular location within an organism (e.g., an organ, a tissue, or a cell, such as a human cell, e.g., a human red blood cell, platelet, neutrophil, or muscle cell).

As used herein, the term “fused” is used to describe the combination or attachment of two or more elements, components, or protein domains, e.g., peptides or polypeptides, by means including chemical conjugation, recombinant means, and chemical bonds, e.g., amide bonds. For example, two single peptides in tandem series can be fused to form one contiguous protein structure, e.g., a polypeptide, through chemical conjugation, a chemical bond, a peptide linker, or any other means of covalent linkage. In some embodiments of a polypeptide described herein, an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) may be fused in tandem series to the N- or C-terminus of a moiety (e.g., Fc domain monomer (e.g., the sequence of SEQ ID NO: 97) a wild-type Fc domain (e.g., the sequence of SEQ ID NO: 150 or SEQ ID NO: 155), an Fc domain with amino acid substitutions (e.g., one or more substitutions that reduce dimerization), an albumin-binding peptide (e.g., the sequence of SEQ ID NO: 151), a fibronectin domain (e.g., the sequence of SEQ ID NO: 152), or a human serum albumin (e.g., the sequence of SEQ ID NO: 153)) by way of a linker. For example, an extracellular ActRIIA variant is fused to a moiety (e.g., an Fc domain monomer, a wild-type Fc domain, an Fc domain with amino acid substitutions (e.g., one or more substitutions that reduce dimerization), an albumin-binding peptide, a fibronectin domain, or a human serum albumin) by way of a peptide linker, in which the N-terminus of the peptide linker is fused to the C-terminus of the extracellular ActRIIA variant through a chemical bond, e.g., a peptide bond, and the C-terminus of the peptide linker is fused to the N-terminus of the moiety (e.g., Fc domain monomer, wild-type Fc domain, Fc domain with amino acid substitutions (e.g., one or more substitutions that reduce dimerization), albumin-binding peptide, fibronectin domain, or human serum albumin) through a chemical bond, e.g., a peptide bond.

As used herein, the term “C-terminal extension” refers to the addition of one or more amino acids to the C-terminus of a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-70 (e.g., SEQ ID NOs: 6-70)). The C-terminal extension can be one or more amino acids, such as 1-6 amino acids (e.g., 1, 2, 3, 4, 5, 6 or more amino acids). The C-terminal extension may include amino acids from the corresponding position of wild-type ActRIIA. Exemplary C-terminal extensions are the amino acid sequence NP (a two amino acid C-terminal extension) and the amino acid sequence NPVTPK (SEQ ID NO: 154) (a six amino acid C-terminal extension). Any amino acid sequence that does not disrupt the activity of the polypeptide can be used. SEQ ID NO: 71, which is the sequence of SEQ ID NO: 69 with a C-terminal extension of NP, and SEQ ID NO: 72, which is the sequence of SEQ ID NO: 69 with a C-terminal extension of NPVTPK (SEQ ID NO: 154), represent two of the possible ways that a polypeptide of the invention can be modified to include a C-terminal extension.

As used herein, the term “percent (%) identity” refers to the percentage of amino acid (or nucleic acid) residues of a candidate sequence, e.g., an extracellular ActRIIA variant, that are identical to the amino acid (or nucleic acid) residues of a reference sequence, e.g., a wild-type extracellular ActRIIA (e.g., SEQ ID NO: 73), after aligning the sequences and introducing gaps, if necessary, to achieve the maximum percent identity (i.e., gaps can be introduced in one or both of the candidate and reference sequences for optimal alignment and non-homologous sequences can be disregarded for comparison purposes). Alignment for purposes of determining percent identity can be achieved in various ways that are within the skill in the art, for instance, using publicly available computer software such as BLAST, ALIGN, or Megalign (DNASTAR) software. Those skilled in the art can determine appropriate parameters for measuring alignment, including any algorithms needed to achieve maximal alignment over the full length of the sequences being compared. In some embodiments, the percent amino acid (or nucleic acid) sequence identity of a given candidate sequence to, with, or against a given reference sequence (which can alternatively be phrased as a given candidate sequence that has or includes a certain percent amino acid (or nucleic acid) sequence identity to, with, or against a given reference sequence) is calculated as follows:

100×(fraction of A/B)

where A is the number of amino acid (or nucleic acid) residues scored as identical in the alignment of the candidate sequence and the reference sequence, and where B is the total number of amino acid (or nucleic acid) residues in the reference sequence. In some embodiments where the length of the candidate sequence does not equal to the length of the reference sequence, the percent amino acid (or nucleic acid) sequence identity of the candidate sequence to the reference sequence would not equal to the percent amino acid (or nucleic acid) sequence identity of the reference sequence to the candidate sequence.

In particular embodiments, a reference sequence aligned for comparison with a candidate sequence may show that the candidate sequence exhibits from 50% to 100% identity across the full length of the candidate sequence or a selected portion of contiguous amino acid (or nucleic acid) residues of the candidate sequence. The length of the candidate sequence aligned for comparison purpose is at least 30%, e.g., at least 40%, e.g., at least 50%, 60%, 70%, 80%, 90%, or 100% of the length of the reference sequence. When a position in the candidate sequence is occupied by the same amino acid (or nucleic acid) residue as the corresponding position in the reference sequence, then the molecules are identical at that position.

As used herein, the term “serum half-life” refers to, in the context of administering a therapeutic protein to a subject, the time required for plasma concentration of the protein in the subject to be reduced by half. The protein can be redistributed or cleared from the bloodstream, or degraded, e.g., by proteolysis. Serum half-life comparisons can be made by comparing the serum half-life of Fc fusion proteins.

As used herein, the term “affinity” or “binding affinity” refers to the strength of the binding interaction between two molecules. Generally, binding affinity refers to the strength of the sum total of non-covalent interactions between a molecule and its binding partner, such as an extracellular ActRIIA variant and BMP9 or activin A. Unless indicated otherwise, binding affinity refers to intrinsic binding affinity, which reflects a 1:1 interaction between members of a binding pair. The binding affinity between two molecules is commonly described by the dissociation constant (K_(D)) or the affinity constant (K_(A)). Two molecules that have low binding affinity for each other generally bind slowly, tend to dissociate easily, and exhibit a large K_(D). Two molecules that have high affinity for each other generally bind readily, tend to remain bound longer, and exhibit a small K_(D). The K_(D) of two interacting molecules may be determined using methods and techniques well known in the art, e.g., surface plasmon resonance. K_(D) is calculated as the ratio of k_(off)/k_(on).

As used herein, the phrase “affecting myostatin, activin A, activin B, and/or BMP9 signaling” means changing the binding of myostatin, activin A, activin B, and/or BMP9 to their receptors, e.g., ActRIIA, ActRIIB, and/or BMPRII (e.g., ActRIIA, e.g., endogenous ActRIIA). In some embodiments, a polypeptide including an extracellular ActRIIA variant described herein reduces or inhibits the binding of myostatin, activin A, activin B, and/or BMP9 to their receptors, e.g., ActRIIA, ActRIIB, and/or BMPRII (e.g., ActRIIA, e.g., endogenous ActRIIA).

As used herein, the terms “increasing” and “decreasing” refer to modulating resulting in, respectively, greater or lesser amounts, of function, expression, or activity of a metric relative to a reference. For example, subsequent to administration of a polypeptide of the invention including an extracellular ActRIIA variant in a method described herein, the amount of a marker of a metric (e.g., platelet or neutrophil count) as described herein may be increased or decreased in a subject relative to the amount of the marker prior to administration. Generally, the metric is measured subsequent to administration at a time that the administration has had the recited effect, e.g., at least one week, one month, 3 months, or 6 months, after a treatment regimen has begun.

As used herein, the terms “bone mineral density (BMD),” “bone density,” and “bone mass” refer to a measure of the amount of bone mineral (e.g., calcium) in bone tissue. BMD may be measured by well-established clinical techniques known to one of skill in the art (e.g., by single-1 or dual-energy photon or X-ray absorptiometry). The concept of BMD relates to the mass of mineral per volume of bone, although clinically it is measured by proxy according to optical density per square centimeter of bone surface upon imaging. BMD measurement is used in clinical medicine as an indirect indicator of osteoporosis and fracture risk. In some embodiments, BMD test results are provided as a T-score, where the T-score represents the BMD of a subject compared to the ideal or peak bone mineral density of a healthy 30-year-old adult. A score of 0 indicates that the BMD is equal to the normal reference value for a healthy young adult. Differences between the measured BMD of subject and that of the reference value for a healthy young adult are measured in standard deviations units (SDs). Accordingly, a T-score of between +1 SD and −1 SD may indicate a normal BMD, a T-score of between −1 SD and −2.5 SD may indicate low bone mass (e.g., osteopenia), and a T-score lower than −2.5 SD may indicate osteoporosis or severe osteoporosis. In some embodiments, a polypeptide of the invention including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), a nucleic acid encoding such a polypeptide, or a vector containing such a nucleic acid molecule is administered to a subject in need thereof, wherein the patient has low bone mass (e.g., a T-Score of between −1 SD and −2.5 SD). In some embodiments, a polypeptide of the invention including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), a nucleic acid encoding such a polypeptide, or a vector containing such a nucleic acid molecule is administered to a subject in need thereof, wherein the patient has osteoporosis (e.g., a T-Score of less than −2.5 SD). In some embodiments, administration of a polypeptide of the invention including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), a nucleic acid encoding such a polypeptide, or a vector containing such a nucleic acid molecule treats the subject by increasing their BMD. In some embodiments, administration of a polypeptide of the invention including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), a nucleic acid encoding such a polypeptide, or a vector containing such a nucleic acid molecule increases the BMD of a subject resulting in an increase in the T-Score of the subject (e.g., resulting in an increase in the T-Score of the subject of 0.1 or more, 0.2 or more, 0.3 or more, 0.4 or more, 0.5 or more, 1.0 or more, or 2.0 or more).

As used herein, the term “bone strength” refers to a measurement of bone that is determined by bone quality in addition to bone mineral density. Bone quality is influenced by bone geometry, microarchitecture, and the properties of constituent tissues. Bone strength can be used to assess the bone's risk of fracture.

As used herein, the term “bone disease” refers to a condition characterized by bone damage (e.g., decreased bone mineral density, decreased bone strength, and/or bone loss). Such diseases or conditions may be caused by an imbalance in osteoblast and/or osteoclast activity (e.g., increased bone resorption or reduced bone formation). Bone diseases include primary osteoporosis, secondary osteoporosis, osteopenia, osteopetrosis, bone fracture, bone cancer or cancer metastasis-related bone loss (e.g., bone loss associated with multiple myeloma), Paget's disease, renal osteodystrophy, osteogenesis imperfecta, neuromuscular disease-related bone loss, burn-induced bone loss, anorexia-related bone loss, treatment-related bone loss, diet-related bone loss, bone loss associated with the treatment of obesity, low gravity-related bone loss, and immobility-related bone loss.

As used herein, the term “neuromuscular disease-related bone loss” refers to bone loss that occurs in a subject having a neuromuscular disease. Poor bone health is often a significant problem for patients with neuromuscular disease. Deficiency of bone mineral density and increased incidence of bone fractures, for example, are a well-recognized clinical consequence of diseases such as DMD, ALS, and SMA.

As used herein, the terms “bone remodeling” or “bone metabolism” refer to the process for maintaining bone strength and ion homeostasis by replacing discrete parts of old bone with newly synthesized packets of proteinaceous matrix. Bone is resorbed by osteoclasts and is deposited by osteoblasts in a process called ossification. Osteocyte activity plays a key role in this process. Conditions that result in a decrease in bone mass, can either be caused by an increase in resorption, or a decrease in ossification. In a healthy individual, during childhood, bone formation exceeds resorption. As the aging process occurs, resorption exceeds formation. Bone resorption rates are also typically much higher in post-menopausal older women due to estrogen deficiency related to menopause.

As used herein, the terms “bone resorption” or “bone catabolic activity” refer to a process by which osteoclasts break down the tissue in bones and release the minerals, resulting in a transfer of the mineral (e.g., calcium) from bone tissue to the blood. Increased rates of bone resorption are associated with aging, including in post-menopausal women. High rates of bone resorption, or rates of bone resorption that exceed the rate of ossification, are associated with bone disorders, such as decreased bone mineral density, including osteopenia and osteoporosis, and can result in bone loss. In some embodiments, a polypeptide of the invention including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), a nucleic acid encoding such a polypeptide, or a vector containing such a nucleic acid molecule is administered to a subject in need thereof to decrease bone resorption in the subject (e.g., the amount or rate of bone resorption in the subject).

As used herein, the terms “bone formation,” “ossification,” “osteogenesis,” or “bone anabolic activity” refer to the process of forming new bone tissue by osteoblasts. In some embodiments, a polypeptide of the invention including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), a nucleic acid encoding such a polypeptide, or a vector containing such a nucleic acid molecule is administered to a subject in need thereof, to increase bone formation (e.g., increase the amount or rate of bone formation or osteogenesis in the subject). Reduced rates of bone formation, or rates of bone formation that are exceeded by the rate of bone resorption, can result in bone loss.

As used herein, the terms “increase red blood cell levels” and “promote red blood cell formation” refer to clinically observable metrics, such as hematocrit, red blood cell counts, and hemoglobin measurements, and are intended to be neutral as to the mechanism by which such changes occur. The term “low red blood cell levels” as used herein refers to red blood cell counts, hematocrit, and hemoglobin measurements that are below the range of values that is considered normal for the subject's age and gender.

As used herein, the terms “red blood cell formation” and “red blood cell production” refer to the generation of red blood cells, such as the process of erythropoiesis in which red blood cells are produced in the bone marrow.

As used herein, the term “anemia” refers to any abnormality in hemoglobin or red blood cells that leads to reduced oxygen levels in the blood. Anemia can be associated with abnormal production, processing, or performance of erythrocytes and/or hemoglobin. The term anemia refers to any reduction in the number of red blood cells and/or level of hemoglobin in blood relative to normal blood levels.

As used herein, the terms “increase platelet levels” and “promote platelet formation” refer to clinically observable metrics, such as platelet counts, and are intended to be neutral as to the mechanism by which such changes occur. The term “low platelet levels” as used herein refers to platelet counts that are below the range of values that is considered normal for the subject's age and gender. The terms “platelet formation” and “platelet production” refer to the generation of platelets, such as the process in which platelets are produced from megakaryocytes.

As used herein, the terms “increase neutrophil levels” and “promote neutrophil formation” refer to clinically observable metrics, such as neutrophil counts, and are intended to be neutral as to the mechanism by which such changes occur. The term “low neutrophil levels” as used herein refers to neutrophil counts that are below the range of values that is considered normal for the subject's age and gender. The terms “neutrophil formation” and “neutrophil production” refer to the generation of neutrophils such as the process in which neutrophils are produced in the bone marrow.

As used herein, the term “thrombocytopenia” refers to a condition in which the blood contains a lower than normal number of platelets, which may be due to a deficiency in platelet production, accumulation of platelets within an enlarged spleen, or the destruction of platelets. Normal blood platelet levels range from about 150,000 to 450,000 per microliter blood in humans. A platelet count of less than 150,000 platelets per microliter is lower than normal. Bleeding can occur after a relatively minor injury if the platelet count falls below 50,000 platelets per microliter of blood, and serious bleeding may occur without any recognized injury if the platelet count falls below 10,000 to 20,000 platelets per microliter of blood.

As used herein, the term “immune thrombocytopenia” is used herein to refer to any type of thrombocytopenia arising from an autoimmune response directed against an individual's own platelets. Immune thrombocytopenia includes primary immune thrombocytopenia, in which autoimmune response is the original cause for the decrease in the platelet counts, such as idiopathic thrombocytopenic purpura. Immune thrombocytopenia also includes secondary immune thrombocytopenia, in which the decrease in platelet counts is associated with one or more other diseases that cause an individual's body to generate an autoimmune response against its own platelets, such as systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), Evans syndrome, immune thyroid disease, leukemia (e.g., chronic lymphocytic leukemia or large granular T-lymphocyte lymphocytic leukemia), or chronic infection (e.g., with Helicobacter pylori, human immunodeficiency virus (HIV), or Hepatitis C).

As used herein, the term “neutropenia” refers to a condition in which the blood contains an abnormally low number of neutrophils. The typical lower limit of the neutrophil count is about 1500 cells per microliter of blood. Below this level, the risk of infection increases. Neutropenia severity is classified as: mild (1000 to 1500 neutrophils per microliter of blood), moderate (500 to 1000 neutrophils per microliter of blood), and severe (below 500 neutrophils per microliter of blood). Neutropenia has many causes, but they typically fall into two main categories: destruction or depletion of neutrophils faster than the bone marrow can produce new neutrophils, or reduced production of neutrophils in the bone marrow.

As used herein, the term “low transfusion burden” refers to a condition of a subject that has received less than four units of red blood cells (RBCs) within eight weeks (e.g., 3, 2, 1, or 0 units of RBCs within eight weeks) prior to treatment with an ActRIIA variant described herein. A subject with a low transfusion burden can be identified as having anemia based on measurements of mean hemoglobin concentration. A subject with a low transfusion burden and a mean hemoglobin concentration of less than 10.0 g/dL of two measurements performed at least one week apart prior to treatment with an ActRIIA variant described herein (e.g., one measurement performed within one day prior to treatment and the other performed 7-28 days prior, not influenced by RBC transfusion within seven days of measurement) is defined as having anemia. In some embodiments, a subject with a low transfusion burden receives 1-3 units of RBCs (1-3 RBC transfusions) within eight weeks prior to treatment with an ActRIIA variant described herein. In some embodiments, a subject with a low transfusion burden does not receive any units of RBCs (0 RBC transfusions) within eight weeks prior to treatment with an ActRIIA variant described herein.

As used herein, the term “high transfusion burden” refers to a condition of a subject requiring greater than or equal to four units of RBCs (e.g., 4, 5, 6, 7, 8, or more units) within eight weeks prior to treatment with an ActRIIA variant described herein. A subject with a high transfusion burden can be identified as having anemia based on measurements of mean hemoglobin concentration. A subject with a high transfusion burden and a mean hemoglobin concentration of less than or equal to 9.0 g/dL is defined as having anemia.

As used herein, the term “ineffective hematopoiesis” refers to the failure to produce fully mature hematopoietic cells (e.g., the failure to produce red blood cells, platelets, and neutrophils). Ineffective hematopoiesis may be due to single or multiple defects, such as abnormal proliferation and/or differentiation of progenitor cells (e.g., an excessive production of progenitors that are unable to complete differentiation), that can lead to a hyperproliferation or a shortage of progenitor cells.

As used herein, the terms “erythropoiesis stimulating agent” and “ESA” refer to a class of drugs that act on the proliferation stage of red blood cell development by expanding the pool of early-stage progenitor cells. Examples of erythropoiesis-stimulating agents are epoetin alfa and darbepoetin alfa.

As used herein, the term “metabolic disease” refers to a disease, disorder, or syndrome that is related to a subject's metabolism, such as breaking down carbohydrates, proteins, and fats in food to release energy, and converting chemicals into other substances and transporting them inside cells for energy utilization and/or storage. Some symptoms of a metabolic disease include high serum triglycerides, high low-density cholesterol (LDL), low high-density cholesterol (HDL), and/or high fasting insulin levels, elevated fasting plasma glucose, abdominal (central) obesity, and elevated blood pressure. Metabolic diseases increase the risk of developing other diseases, such as cardiovascular disease. In the present invention, metabolic diseases include, but are not limited to, obesity, Type 1 diabetes, and Type 2 diabetes.

As used herein, the term “treatment-related metabolic disease” refers to a metabolic disease (e.g., obesity, Type 1 diabetes, or Type 2 diabetes) associated with a medication taken by the subject (e.g., a metabolic disease developed during treatment with the medication). The medication can be one that the subject continues to take, or one taken previously that led to the development of metabolic disease. Medications associated with the development of obesity include glucocorticoids (e.g., corticosteroids, such as prednisone), selective serotonin reuptake inhibitors (SSRIs, e.g., paroxetine, mirtazapine, fluoxetine, escitalopram, sertraline), tricyclic antidepressants (e.g., amitriptyline), mood stabilizers (e.g., valproic acid, lithium), antipsychotics (e.g., olanzapine, chlorpromazine, clozapine), and diabetes medication (e.g., insulin, chlorpropamide). Medications associated with the development of diabetes include glucocorticoids (e.g., corticosteroids, which may cause glucocorticoid-induced diabetes mellitus), SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs), mood stabilizers (e.g., lithium and valproic acid), and antipsychotics (e.g., olanzapine and clozapine). In some embodiments, the development of obesity may lead to the development of diabetes.

As used herein, the term “age-related metabolic disease” refers to a metabolic disease (e.g., obesity, Type 1 diabetes, or Type 2 diabetes) that develops with age. For example, the risk of diabetes increases with age and is more common in older adults, with approximately 25% of adults over 60 having diabetes. Adults can develop Type 2 diabetes or new-onset Type 1 diabetes. Rates of obesity also increase with age, with the highest rates of obesity in the United States occurring in adults aged 40-59 (with a prevalence of obesity of 45%). Aging also reduces the body's ability to burn fat, leading to increased fat surrounding internal organs.

As used herein, the term “percentage of body weight gain” refers to the percentage of gained body weight compared to a prior body weight of a subject at a prior time. The percentage of body weight gain can be calculated as follows:

100×[(body weight at a later time−body weight at a prior time)/(body weight at a prior time)]

In the present invention, administration of a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), a nucleic acid molecule encoding a such polypeptide, or vector containing such a nucleic acid molecule to a subject can reduce the percentage of body weight gain of the subject.

As used herein, the term “appetite for food intake” refers to a subject's natural desire or need for food. The appetite for food intake of a subject can be monitored by measuring the amount of food consumed after the polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) is administered. In the present invention, administration of a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), a nucleic acid molecule encoding such a polypeptide, or vector containing such a nucleic acid molecule to a subject does not affect the subject's appetite for food intake.

As used herein, the term “adiposity” refers to the fat stored in the adipose tissue of a subject. In the present invention, administration of a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), a nucleic acid molecule encoding such a polypeptide, or vector containing such a nucleic acid molecule to a subject can reduce the subject's adiposity without affecting lean mass.

As used herein, the term “epididymal and perirenal fat pads” refers to the tightly packed fat cells in the epididymis and around the kidney. In the present invention, administration of a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), a nucleic acid molecule encoding such a polypeptide, or vector containing such a nucleic acid molecule to a subject can reduce the weights of epididymal and perirenal fat pads of the subject.

As used herein, the term “fasting insulin” refers to a subject's level of insulin while the subject has not had any food intake for a length of time (i.e., 12-24 hours). Fasting insulin level is used in diagnosing metabolic diseases. Fasting insulin level is also used as an indication of whether a subject is at the risk of developing a metabolic disease. Normally, in a subject suffering from Type 1 diabetes, the subject's fasting insulin level is low compared to that of a healthy subject. In a subject suffering from insulin resistance (i.e., Type 2 diabetes), the subject's fasting insulin level is high compared to that of a healthy subject. In the present invention, administration of a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), a nucleic acid molecule encoding such a polypeptide, or vector containing such a nucleic acid molecule to a subject can modulate the subject's fasting insulin level.

As used herein, the term “rate of glucose clearance” refers to the rate at which glucose is being cleared from the blood. The rate of glucose clearance can be measured in a glucose tolerance test (GTT). In a GTT, a subject is given a certain amount of glucose and blood samples are taken afterward to determine how quickly it is cleared from the blood. The rate of glucose clearance can be used as a parameter in diagnosing and/or determining the risk of developing metabolic diseases such as obesity, diabetes, and insulin resistance.

As used herein, the term “serum lipid profile” refers to the measurement of the distribution of different types of lipids and lipoproteins in a subject's serum. Such measurement can be accomplished by a panel of blood tests. The types of lipids and lipoproteins in a subject's serum include, but are not limited to, cholesterol (e.g., high-density lipoprotein (HDL) and low-density lipoprotein (LDL)), triglyceride, and free fatty acid (FFA). The distribution of the different types of lipids and lipoproteins can be used as a parameter in diagnosing and/or determining the risk of developing metabolic diseases such as obesity, diabetes, and insulin resistance. High levels of cholesterol, especially low-density lipoprotein, is generally regarded as an indication or risk factor for developing certain metabolic diseases, or in some severe medical cases, cardiovascular diseases. In the present invention, administration of a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), a nucleic acid molecule encoding such a polypeptide, or vector containing such a nucleic acid molecule to a subject improves the subject's serum lipid profile such that the levels of cholesterol (especially low-density lipoprotein) and triglyceride are lowered.

As used herein, the term “vascular complication” refers to a vascular disorder or any damage to the blood vessels, such as damage to the blood vessel walls. Damage to the blood vessel walls may cause an increase in vascular permeability or leakage. The term “vascular permeability or leakage” refers to the capacity of the blood vessel walls to allow the flow of small molecules, proteins, and cells in and out of blood vessels. An increase in vascular permeability or leakage may be caused by an increase in the gaps (e.g., an increase in the size and/or number of the gaps) between endothelial cells that line the blood vessel walls and/or thinning of the blood vessel walls.

As used herein, the term “lean mass” refers to a component of body composition which includes, e.g., lean mass, body fat, and body fluid. Normally lean mass is calculated by subtracting the weights of body fat and body fluid from total body weight. Typically, a subject's lean mass is between 60% and 90% of totally body weight. In the present invention, administration of a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), a nucleic acid molecule encoding such a polypeptide, or vector containing such a nucleic acid molecule to a subject increases the subject's lean mass.

As used herein, the term “muscle mass” refers to the primary component of lean mass. Muscle mass can be measured experimentally by measuring muscle weight.

As used herein, the term “neuromuscular disease” refers to a disease that affects voluntary or involuntary muscle function due to problems in the nerves and muscles, typically leading to muscle weakness. Exemplary neuromuscular diseases include amyotrophic lateral sclerosis (ALS), autonomic neuropathy, botulism, Charcot-Marie-Tooth disease (CMT), chronic inflammatory demyelinating polyradiculoneuropathy, congenital myasthenic syndrome, congenital myopathies, cramp-fasciculation syndrome, dermatomyositis, diabetic neuropathy, distal myopathies, dystrophinopathies, endocrine myopathies, focal muscular atrophies, glycogen storage disease type II, Guillain-Barre syndrome, hereditary spastic paraplegia, inclusion body myositis (IBM), Isaac's syndrome, Kearns-Sayre syndrome, Kennedy disease, Lambert-Eaton myasthenic syndrome, metabolic myopathies, metabolic neuropathies, mitochondrial myopathies, motor neuron diseases, multiple sclerosis, muscular dystrophy (e.g., Duchenne (DMD), Becker (BMD), myotonic (DM), facioscapulohumeral (FSHD), limb-girdle (LGMD), distal (DD), oculopharyngeal (OPMD), Emery-Dreifuss (EDMD), and congenital (e.g., MDC1A, MDC1B, MDC1C, FCMD, WWS, RSMD1, MEB, and UCMD)), myasthenia gravis, myotonic dystrophy, necrotizing myopathies, neuromyotonia, neuropathy of Friedreich's Ataxia, nutritional neuropathy, peripheral neuropathy, polymyositis, primary lateral sclerosis, Schwartz-Jampel Syndrome, small fiber neuropathy, spinal and bulbar muscular atrophy, spinal muscular atrophy, spinal muscular atrophy with respiratory distress type 1, spinocerebellar ataxia, stiff person syndrome, toxic neuropathy, and Troyer syndrome. A neuromuscular disease may be inherited in an autosomal dominant or recessive pattern or mutations may occur spontaneously.

As used herein, the term “polypeptide” describes a single polymer in which the monomers are amino acid residues which are covalently conjugated together through amide bonds. A polypeptide is intended to encompass any amino acid sequence, either naturally occurring, recombinant, or synthetically produced.

As used herein, the term “homodimer” refers to a molecular construct formed by two identical macromolecules, such as proteins or nucleic acids. The two identical monomers may form a homodimer by covalent bonds or non-covalent bonds. For example, an Fc domain may be a homodimer of two Fc domain monomers if the two Fc domain monomers contain the same sequence. In another example, a polypeptide described herein including an extracellular ActRIIA variant fused to an Fc domain monomer may form a homodimer through the interaction of two Fc domain monomers, which form an Fc domain in the homodimer.

As used herein, the term “heterodimer” refers to a molecular construct formed by two different macromolecules, such as proteins or nucleic acids. The two monomers may form a heterodimer by covalent bonds or non-covalent bonds. For example, a polypeptide described herein including an extracellular ActRIIA variant fused to an Fc domain monomer may form a heterodimer through the interaction of two Fc domain monomers, each fused to a different ActRIIA variant, which form an Fc domain in the heterodimer.

As used herein, the term “host cell” refers to a vehicle that includes the necessary cellular components, e.g., organelles, needed to express proteins from their corresponding nucleic acids. The nucleic acids are typically included in nucleic acid vectors that can be introduced into the host cell by conventional techniques known in the art (transformation, transfection, electroporation, calcium phosphate precipitation, direct microinjection, etc.). A host cell may be a prokaryotic cell, e.g., a bacterial cell, or a eukaryotic cell, e.g., a mammalian cell (e.g., a CHO cell or a HEK293 cell).

As used herein, the term “therapeutically effective amount” refers an amount of a polypeptide, nucleic acid, or vector of the invention or a pharmaceutical composition containing a polypeptide, nucleic acid, or vector of the invention effective in achieving the desired therapeutic effect in treating a patient having a disease or condition, such as a disease or condition involving weakness and atrophy of muscles (e.g., a neuromuscular disease, such as a muscular dystrophy, SMA, CMT, myasthenia gravis, or multiple sclerosis; or cachexia), a disease or condition involving bone damage (e.g., osteogenesis imperfecta, neuromuscular disease-related bone loss, burn-induced bone loss, or anorexia-related bone loss), a disease or condition involving low red blood cell levels (e.g., myelofibrosis or a myelodysplastic syndrome), a disease or condition involving low platelet levels (e.g., thrombocytopenia), a disease or condition involving low neutrophil levels (e.g., neutropenia), or a metabolic disease. In particular, the therapeutically effective amount of the polypeptide, nucleic acid, or vector avoids adverse side effects.

As used herein, the term “pharmaceutical composition” refers to a medicinal or pharmaceutical formulation that includes an active ingredient as well as excipients and diluents to enable the active ingredient suitable for the method of administration. The pharmaceutical composition of the present invention includes pharmaceutically acceptable components that are compatible with the polypeptide, nucleic acid, or vector. The pharmaceutical composition may be in tablet or capsule form for oral administration or in aqueous form for intravenous or subcutaneous administration.

As used herein, the term “pharmaceutically acceptable carrier or excipient” refers to an excipient or diluent in a pharmaceutical composition. The pharmaceutically acceptable carrier must be compatible with the other ingredients of the formulation and not deleterious to the recipient. In the present invention, the pharmaceutically acceptable carrier or excipient must provide adequate pharmaceutical stability to the polypeptide including an extracellular ActRIIA variant, the nucleic acid molecule(s) encoding the polypeptide, or a vector containing such nucleic acid molecule(s). The nature of the carrier or excipient differs with the mode of administration. For example, for intravenous administration, an aqueous solution carrier is generally used; for oral administration, a solid carrier is preferred.

As used herein, the term “treating and/or preventing” refers to the treatment and/or prevention of a disease or condition, e.g., a disease or condition involving weakness and atrophy of muscles (e.g., a neuromuscular disease, such as a muscular dystrophy, SMA, CMT, myasthenia gravis, or multiple sclerosis; or cachexia), a disease or condition involving bone damage (e.g., osteogenesis imperfecta, neuromuscular disease-related bone loss, burn-induced bone loss, or anorexia-related bone loss), a disease or condition involving low red blood cell levels (e.g., myelofibrosis or a myelodysplastic syndrome), a disease or condition involving low platelet levels (e.g., thrombocytopenia), a disease or condition involving low neutrophil levels (e.g., neutropenia), or a metabolic disease, using methods and compositions of the invention. Generally, treating a disease or condition involving weakness and atrophy of muscles, bone damage, low red blood cell levels, low platelet levels, low neutrophil levels, or a metabolic disease occurs after a subject has developed the disease or condition. Preventing a disease or condition involving weakness and atrophy of muscles, bone damage, low red blood cell levels, low platelet levels, low neutrophil levels, or a metabolic disease refers to steps or procedures taken when a subject is at risk of developing the disease or condition. The subject may show signs or mild symptoms that are judged by a physician to be indications or risk factors for developing a disease or condition involving weakness and atrophy of muscles, bone damage, low red blood cell levels, low platelet levels, low neutrophil levels, or a metabolic disease, have another disease or condition associated with the development of a disease or condition involving weakness and atrophy of muscles, bone damage, low red blood cell levels, low platelet levels, low neutrophil levels, or a metabolic disease, be undergoing treatment that may cause a disease or condition involving weakness and atrophy of muscles, bone damage, low red blood cell levels, low platelet levels, low neutrophil levels, or a metabolic disease, or have a family history or genetic predisposition of developing a disease or condition involving weakness and atrophy of muscles, bone damage, low red blood cell levels, low platelet levels, low neutrophil levels, or a metabolic disease, but has not yet developed the disease or condition.

As used herein, the term “subject” refers to a mammal, e.g., preferably a human. Mammals include, but are not limited to, humans and domestic and farm animals, such as monkeys (e.g., a cynomolgus monkey), mice, dogs, cats, horses, and cows, etc.

DESCRIPTION OF THE DRAWINGS

FIG. 1 is a sequence alignment showing the wild-type sequences of extracellular ActRIIA and ActRIIB and the sequences of exemplary ActRIIA variants. Sequences shown in FIG. 1 include an extracellular portion of ActRIIa (SEQ ID NO: 165, which corresponds to amino acids 12-92 of SEQ ID NO: 73), an extracellular portion of ActRIIB (SEQ ID NO: 166, which corresponds to amino acids 10-90 of SEQ ID NO: 74), ActRIIA/B (SEQ ID NO: 69), ActRIIA/Bdelta9 (SEQ ID NO: 58), ActRIIA/Bdelta9 min (SEQ ID NO: 6), ActRIIA/B+ (SEQ ID NO: 149), ActRIIa/bdelta9m2 (SEQ ID NO: 38), ActRIIa/bdelta9m3 (SEQ ID NO: 41), ActRIIa/bdelta9m4 (SEQ ID NO: 44), ActRIIa/bmax1 (SEQ ID NO: 70), ActRIIa/bmax2 (SEQ ID NO: 71), and ActRIIa/bmax3 (SEQ ID NO: 72).

FIGS. 2A-2C are a series of graphs showing the effect of ActRIIA/B-mFc (SEQ ID NO: 69 linked to a mouse Fc domain) on erythroid burst-forming units (BFU-E), erythroid colony-forming units (CFU-E), and proerythroblasts (Pro-E) in C57BL/6 mice.

FIGS. 3A-3D are a series of graphs showing the effect of ActRIIA/B-mFc on red blood cell count, hematocrit, hemoglobin, and neutrophils after 14 days of twice weekly treatment in C57BL/6 mice.

FIGS. 4A-4D are a series of graphs showing the effect of ActRIIA/B-mFc on red blood cell count, hemoglobin, hematocrit, and neutrophil count in 2-year old C57BL/6 mice. N=8-9, **p<0.01, ***p<0.001, ****p<0.0001 by one-way ANOVA with a Dunnett's post test. Data are shown as the mean±SEM.

FIGS. 5A-5C are a series of graphs showing the effect of ActRIIA/B-mFc on red blood cell levels, hemoglobin concentration, and hematocrit in C57BL/6 mice treated with an erythropoietin neutralizing antibody (EPO mAb).

FIG. 6 is a pair of graphs showing the effect of ActRIIA/B-hFc (SEQ ID NO: 69 linked to a human IgG1 Fc domain) on reticulocytes in female (left) and male (right) cynomolgus monkeys.

FIGS. 7A-7C are a series of graphs showing the effect of ActRIIA/B-hFc on reticulocytes, hemoglobin, and red blood cells in human subjects. Treatment led to robust and sustained increases in reticulocytes, hemoglobin, and red blood cells after a single dose.

FIG. 8 is a graph showing the proportion of subjects treated with ActRIIA/B-hFc that exhibited a change in hemoglobin ≥1.5 g/dL for the single ascending dose and multiple dose cohorts.

FIG. 9 is a graph showing the effect of ActRIIA/B-hFc on platelets in human subjects. Treatment led to clinically meaningful changes in platelets after a single dose.

FIG. 10 is a graph showing serum levels of ActRIIA/B-hFc in subjects treated with a single dose of ActRIIA/B-hFc. Dose proportional increases in C_(max) and AUC were observed.

FIG. 11 is a graph showing the effect of ActRIIA/B-hFc on follicle stimulating hormone (FSH) in human subjects. FSH was used as a biomarker for target engagement. Treatment with ActRIIA/B-hFc led to a decrease in serum FSH.

FIG. 12 is a graph showing the effect of ActRIIA/B-hFc on bone-specific alkaline phosphatase (BSAP) in human subjects. BSAP was used as a serum biomarker of bone growth. Treatment with ActRIIA/B-hFc led to an increase in serum BSAP.

FIG. 13 is a graph showing that a single 10 mg/kg dose of ActRIIA/B-mFc administered by intraperitoneal (IP) injection to 11-week-old male mice increased serum EPO levels 4, 7, and 14 days after injection compared to vehicle. Red blood cells were increased at each time point. *p<0.05, **p<0.01, ****p<0.0001 between ActRIIA/B-mFc-treated and vehicle at each time point with 2-way ANOVA followed by a Sidak post test. Data are shown as the mean±SEM.

FIG. 14 is a graph showing that a single 10 mg/kg dose of ActRIIA/B-mFc administered by intraperitoneal (IP) injection to 11-week-old male mice had a long lasting effect on EPO and increased serum EPO levels by day 4 through day 37. *p≤0.05; **p≤0.01; p****<0.0001 between ActRIIA/B-mFc-treated and vehicle at each time point by t-test. Data are shown as the mean±SEM.

FIG. 15 is a series of graphs showing that a single 10 mg/kg dose of ActRIIA/B-mFc administered by IP injection to 11-week-old male mice increased EPO receptor levels in bone marrow cells on day 7 and day 14 after injection compared to vehicle. Error bars represent SEM.

FIGS. 16A-16C are a series of graphs showing that a single dose of ActRIIA/B-mFc at 10 mg/kg increased red blood cells, hemoglobin, and reticulocytes just 12 hours after administration compared to vehicle-treated mice (FIG. 16A). This effect was further increased on day 7 (FIG. 16B) and sustained through day 14 post-dose (FIG. 16C). D7 and D14 N=6; 12H N=10. *p<0.05, **p<0.01, ***p<0.001 by Student's t-test. NS=not significant. Error bars are ±SEM.

FIGS. 17A-17B are a series of graphs showing that administration of a single dose of ActRIIA/B-mFc at 10 mg/kg resulted in a long-lasting effect on erythropoiesis and increased red blood cells (FIG. 17A) and hemoglobin (FIG. 17B) through at least day 51 compared to vehicle-treated mice. 12-24HR N=19; Days 37 and 51 N=10. *p≤0.05; **p≤0.01; p****≤0.0001 compared to vehicle at each time point by t-test. Data are shown as the mean±SEM.

FIGS. 18A-18C are a series of graphs showing that ActRIIA/B-mFc administered at 10 mg/kg by IP injection increased the EryC population at day 7 after treatment (FIG. 18A), decreased the number of nucleated cells in bone marrow at day 2 after treatment (FIG. 18B), and increased the percentage of immature reticulocytes in circulation at day 2 after treatment (FIG. 18C). N=6. *p<0.05, **p<0.01 by Student's t-test. Error bars are ±SEM.

FIGS. 19A-19B are a series of graphs showing that a single 10 mg/kg dose of ActRIIA/B-mFc administered by IP injection increased the number of CFU-E colonies at day 2 post-dose (FIG. 19A) and decreased the EryB cell pool at day 4 (FIG. 19B). EryB cells were then repleted by day 7 (FIG. 19B). N=4-7, *p<0.05.

FIGS. 20A-20F are a series of graphs showing that a 10 mg/kg dose of ActRIIA/B-mFc administered by IP injection increased BFU-E colonies (FIG. 20A), decreased ProE (FIG. 20C), and increased EryA, EryB and EryC precursor populations (FIGS. 20D-20F) at day 14 post-dose. *p<0.05, **p<0.01, ***p<0.001, ****p<0.0001 by Student's t-test. Error bars are ±SEM.

FIG. 21 is a series of graphs showing that twice weekly dosing with 7.5 mg/kg of ActRIIA/B-mFc administered by IP injection increased RBC number, hemoglobin, and hematocrit in a mouse model of a myelodysplastic syndrome (NUP98/HOXD13 transgenic mice). Statistical analysis was performed by repeat measures two-way ANOVA. Individual comparisons were calculated with a Sidak post test and shown as *p<0.05, **p<0.01. P values are given for the overall significance between treatments. Data are shown as the mean±SEM.

FIGS. 22A-22C are a series of graphs showing that a single dose of ActRIIA/B-mFc at 10 mg/kg administered by subcutaneous injection enhanced recovery in a model of acute blood loss anemia, increasing RBCs (FIG. 22A), hemoglobin (FIG. 22B), and hematocrit (FIG. 22C). N=4 (Vehicle), N=5 (ActRIIA/B-mFc). Statistical analysis performed by repeat measures two-way ANOVA. Individual comparisons were calculated with a Sidak post test and shown as *p<0.05, **p<0.01. P values are given for the overall significance between treatments. Data are shown as the mean±SEM.

FIG. 23 is a graph showing that subcutaneous dosing with 10 mg/kg ActRIIA/B-mFc every 4 days increased platelets after phlebotomy in rats. N=5. Two-way ANOVA was used for statistical analysis. *p<0.05 for ActRIIA/B-mFc-treated Day 3 compared to ActRIIA/B-mFc-treated Day 0. Error bars are ±SEM.

FIG. 24 is a graph showing that intraperitoneal dosing with 7.5 mg/kg ActRIIA/B-hFc in eight-week-old female C57Bl/6 mice increased circulating platelets four days post dosing. N=10. ****=P<0.0001 by Student's t-test. Error bars are ±SEM.

FIG. 25 is a series of graphs showing that administration of a single 10 mg/kg dose of ActRIIA/B-mFc to 10-14-week-old wild type male C57Bl/6 mice via IP injection led to increased platelet volume at 24 hours (N=6 per group), 37 days (N=10 per group), and 51 days (N=10 per group) post-dose. Data are shown as average±SEM. Statistics are shown in comparison to vehicle treatment using an unpaired t-test. *P<0.05 and ***P<0.001.

DETAILED DESCRIPTION OF THE INVENTION

The invention features polypeptides that include an extracellular activin receptor type IIA (ActRIIA) variant. In some embodiments, a polypeptide of the invention includes an extracellular ActRIIA variant fused to a moiety (e.g., Fc domain monomer, a wild-type Fc domain, an Fc domain with amino acid substitutions (e.g., one or more substitutions that reduce dimerization), an albumin-binding peptide, a fibronectin domain, or a human serum albumin). A polypeptide including an extracellular ActRIIA variant fused to an Fc domain monomer may also form a dimer (e.g., homodimer or heterodimer) through the interaction between two Fc domain monomers. The ActRIIA variants described herein have weak binding affinity or no binding affinity to bone morphogenetic protein 9 (BMP9) compared to activins and myostatin. The invention also includes methods of treating diseases and conditions involving weakness and atrophy of muscles (e.g., neuromuscular diseases, cachexia, disuse atrophy, and hypotonia), methods of treating or preventing bone damage (e.g., osteogenesis imperfecta or burn injury-related or anorexia-related bone loss), methods of treating or preventing low blood cell levels (e.g., anemia, such as anemia related to myelofibrosis or a myelodysplastic syndrome) by increasing red blood cell levels (e.g., red blood cell count, hemoglobin levels, or hematocrit), red blood cell production, erythroid progenitor maturation and/or differentiation (e.g., the maturation and/or differentiation of early-stage or late- (e.g., terminal) stage erythroid progenitors into proerythroblasts, reticulocytes, or red blood cells), late-stage precursor (erythroid precursor) maturation (e.g., terminal maturation, such as the maturation of reticulocytes into red blood cells or the maturation of erythroblasts into reticulocytes and/or red blood cells), by recruiting early-stage progenitors into the erythroid lineage, by reducing the accumulation of red blood cell progenitor cells (e.g., by stimulating progenitor cells to progress to maturation), by increasing the number of early-stage erythroid precursors and/or progenitors (e.g., by expanding the early-stage precursor and/or progenitor populations to provide a continuous supply of precursors to replenish polychromatic erythroblasts and allow for a continuous supply of maturing reticulocytes), or by promoting the progression of erythroid precursors and/or progenitors through erythropoiesis, methods of treating or preventing low platelet levels (e.g., thrombocytopenia) by increasing platelet levels (e.g., platelet count, megakaryocyte differentiation and/or maturation, and/or platelet production) or by reducing the accumulation of platelet progenitor cells (e.g., by stimulating progenitor cells to progress to maturation), methods of treating or preventing low neutrophil levels (e.g., neutropenia) by increasing neutrophil levels (e.g., neutrophil count, e.g., neutrophil production) or differentiation and/or maturation of progenitor cells (e.g., myeloid progenitors, myeloblasts, or myelocytes) into neutrophils, methods of treating or preventing age-related or treatment-related metabolic disease (e.g., obesity, Type 1 diabetes, or Type 2 diabetes), or methods of affecting myostatin, activin A, activin B, and/or BMP9 signaling in a subject by administering to the subject a polypeptide including an extracellular ActRIIA variant described herein.

I. Extracellular Activin Receptor Type IIA (ActRIIA) Variants

Activin type II receptors are single transmembrane domain receptors that modulate signals for ligands in the transforming growth factor β (TGF-β) superfamily. Ligands in the TGF-β superfamily are involved in a host of physiological processes, such as muscle growth, vascular growth, cell differentiation, homeostasis, and osteogenesis. Examples of ligands in the TGF-β superfamily include, e.g., activin A, activin B, inhibin, growth differentiation factors (GDFs) (e.g., GDF8, also known as myostatin, and GDF11), and bone morphogenetic proteins (BMPs) (e.g., BMP9).

Myostatin and activins are known to play a role in the regulation of skeletal muscle growth. For example, mice without myostatin show a large increase in skeletal muscle mass. In addition, activins are expressed abundantly in bone tissues and regulate bone formation by controlling both osteoblast and osteoclast functions. Activin A has been reported to be upregulated in bone disease and inhibits osteoblast activity. Myostatin is also implicated in bone homeostasis through increasing osteogenesis and inhibiting osteoblast activity. TGF-β signaling pathways also regulate hematopoiesis, with signaling pathways involving activins preventing the differentiation of red blood cell, platelet, and neutrophil progenitor cells in order to maintain progenitor cells in a quiescent state, and signaling pathways involving BMPs promoting differentiation of progenitor cells. Homeostasis of this process is essential to ensure that all cell types, including red cells, white cells, and platelets, are properly replenished in the blood. Relatedly, activin receptor ligand GDF11 has been found to be overexpressed in a mouse model of hemolytic anemia and associated with defects in red blood cell production. Furthermore, activins are highly expressed in adipose tissue, and increased myostatin levels and activin receptor levels have been observed in subcutaneous and visceral fat of obese mice. Additionally, myostatin has been shown to be elevated in skeletal muscle and plasma of obese and insulin resistant women, and both type I and type II activin receptors have been linked to pancreatic function and diabetes. These data suggest that increased signaling through activin receptors, either due to increased expression of activin receptor ligands (e.g., activin A, activin B, myostatin) or increased expression of activin receptors themselves, could contribute to a variety of diseases and conditions, including muscle atrophy or weakness, bone disease, anemia, thrombocytopenia, neutropenia, and metabolic disease. Methods that reduce or inhibit activin A, activin B, and/or myostatin signaling could, therefore, be used in the treatment of diseases and conditions involving muscle atrophy or weakness (e.g., neuromuscular diseases), bone damage (e.g., osteogenesis imperfecta), low red blood cell levels (e.g., anemia), low platelet levels (e.g., thrombocytopenia), low neutrophil levels (e.g., neutropenia), or metabolic disorders (e.g., age-related or treatment-related metabolic disorder).

There exist two types of activin type II receptors: ActRIIA and ActRIIB. Studies have shown that BMP9 binds ActRIIB with about 300-fold higher binding affinity than ActRIIA (see, e.g., Townson et al., J. Biol. Chem. 287:27313, 2012). ActRIIA-Fc is known to have a longer half-life compared to ActRIIB-Fc. The present invention describes extracellular ActRIIA variants that are constructed by introducing amino acid residues of ActRIIB to ActRIIA, with the goal of imparting physiological properties conferred by ActRIIB, while also maintaining beneficial physiological and pharmacokinetic properties of ActRIIA. The optimum peptides increase muscle mass or lean mass, reduce bone damage, increase red blood cell levels (e.g., increase red blood cell production, increase red blood cell count, increase hemoglobin levels, or increase hematocrit), increase erythroid progenitor (e.g., early and/or terminal stage erythroid progenitor) maturation and/or differentiation, recruit early-stage progenitors into the erythroid lineage, increase late-stage erythroid precursor maturation (e.g., terminal maturation, such as the maturation of reticulocytes into red blood cells, or the maturation of erythroblasts into reticulocytes and/or red blood cells), increase the number of early-stage erythroid precursors and/or progenitors (e.g., expand the early-stage precursor and/or progenitor populations), promote the progression of erythroid precursors and/or progenitors through erythropoiesis, increase platelet levels (e.g., increase platelet count), and/or increase neutrophil levels (e.g., increase neutrophil count), while retaining low binding-affinity to BMP9 and longer serum half-life as an Fc fusion protein, for example. The preferred ActRIIA variants also exhibit similar or improved binding to activins and/or myostatin compared to wild-type ActRIIA, which allows them to compete with endogenous activin receptors for ligand binding and reduce or inhibit endogenous activin receptor signaling. These variants can be used to treat disorders in which activin receptor signaling is elevated, such as muscle disease (e.g., neuromuscular disease, cachexia, hypotonia or disuse atrophy), bone disease (e.g., osteogenesis imperfecta or burn injury-related or anorexia-related bone loss), anemia (e.g., anemia associated with myelofibrosis or a myelodysplastic syndrome), thrombocytopenia, neutropenia, or metabolic disease (e.g., age-related or treatment-related metabolic disease) by increasing lean mass or muscle strength, reducing bone resorption, increasing bone mineral density or bone formation, increasing red blood cell levels (e.g., increasing hemoglobin levels, hematocrit, or red blood cell count, e.g., increasing red blood cell production and/or red cell mass or volume), increasing erythroid progenitor maturation and/or differentiation (e.g., the maturation and/or differentiation of early-stage or late- (e.g., terminal) stage erythroid progenitors into proerythroblasts, reticulocytes, or red blood cells), reducing the accumulation of red blood cell progenitor cells (e.g., by stimulating progenitor cells to progress to maturation), increasing late-stage precursor (erythroid precursor) maturation (e.g., terminal maturation, such as the maturation of reticulocytes into red blood cells, or the maturation of erythroblasts into reticulocytes and/or red blood cells), recruiting early-stage progenitors into the erythroid lineage, increasing the number of early-stage erythroid precursors and/or progenitors, promoting the progression of erythroid precursors and/or progenitors through erythropoiesis (e.g., progression through the erythropoiesis pathway), increasing platelet levels (e.g., increasing platelet count, megakaryocyte differentiation and/or maturation, and/or platelet production), reducing the accumulation of platelet progenitor cells (e.g., by stimulating progenitor cells to progress to maturation), increasing neutrophil levels (e.g., increasing neutrophil count, e.g., increasing neutrophil production), increasing the differentiation and/or maturation of progenitor cells (e.g., myeloid progenitors, myeloblasts, or myelocytes) into neutrophils, or reducing body fat, body weight, blood glucose levels, or insulin resistance. In some embodiments, amino acid substitutions may be introduced to an extracellular ActRIIA variant to reduce or remove the binding affinity of the variant to BMP9. The wild-type amino acid sequences of the extracellular portions of human ActRIIA and ActRIIB are shown below.

Human ActRIIA, extracellular portion  (SEQ ID NO: 73): GAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFATWKNIS GSIEIVKQGCWLDDINCYDRTDCVEKKDSPEVYFCCCEGNMCNEKFSYFP EMEVTQPTS Human ActRIIB, extracellular portion  (SEQ ID NO: 74): GRGEAETRECIYYNANWELERTNQSGLERCEGEQDKRLHCYASWRNSSGT IELVKKGCWLDDFNCYDRQECVATEENPQVYFCCCEGNFCNERFTHLPEA GGPEVTYEPPPTAPT

Polypeptides described herein include an extracellular ActRIIA variant having at least one amino acid substitution relative to the wild-type extracellular ActRIIA having the sequence of SEQ ID NO: 73 or the extracellular ActRIIA having any one of the sequences of SEQ ID NOs: 76-96. Possible amino acid substitutions at 27 different positions may be introduced to an extracellular ActRIIA variant (Table 1). In some embodiments, an extracellular ActRIIA variant may have at least 85% (e.g., at least 85%, 87%, 90%, 92%, 95%, 97%, or greater) amino acid sequence identity to the sequence of a wild-type extracellular ActRIIA (SEQ ID NO: 73). An extracellular ActRIIA variant may have one or more (e.g., 1-27, 1-25, 1-23, 1-21, 1-19, 1-17, 1-15, 1-13, 1-11, 1-9, 1-7, 1-5, 1-3, or 1-2; e.g., 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, or 27) amino acid substitutions relative the sequence of a wild-type extracellular ActRIIA (SEQ ID NO: 73). In some embodiments, an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having a sequence of SEQ ID NO: 1) may include amino acid substitutions at all of the 27 positions as listed in Table 1. In some embodiments, an extracellular ActRIIA variant may include amino acid substitutions at a number of positions, e.g., at 2, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, 24, or 26 out of the 27 positions, as listed in Table 1.

Amino acid substitutions can worsen or improve the activity and/or binding affinity of the ActRIIA variants of the invention. To maintain polypeptide function, it is important that the lysine (K) at position X₁₇ in the sequences shown in Tables 1 and 2 (SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) be retained. Substitutions at that position can lead to a loss of activity. For example, an ActRIIA variant having the sequence

GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCYATWRNISGSIEIVAKGCWLDDFNCYD RTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS (SEQ ID NO: 149) has reduced activity in vivo, indicating that the substitution of alanine (A) for lysine (K) at X₁₇ is not tolerated. ActRIIA variants of the invention, including variants in Tables 1 and 2 (e.g., SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72), therefore, retain amino acid K at position X₁₇.

The ActRIIA variants of the invention preferably have reduced, weak, or no substantial binding to BMP9. BMP9 binding is reduced in ActRIIA variants (e.g., reduced compared to wild-type ActRIIA) containing the amino acid sequence TEEN (SEQ ID NO: 161) at positions X₂₃, X₂₄, X₂₅, and X₂₆, as well as in variants that maintain the amino acid K at position X₂₄ and have the amino acid sequence TKEN (SEQ ID NO: 162) at positions X₂₃, X₂₄, X₂₅, and X₂₆. The sequences TEEN (SEQ ID NO: 161) and TKEN (SEQ ID NO: 162) can be employed interchangeably in the ActRIIA variants (e.g., the variants in Tables 1 and 2, e.g., SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) of the invention to provide reduced BMP9 binding.

The ActRIIA variants of the invention may further include a C-terminal extension (e.g., additional amino acids at the C-terminus). The C-terminal extension can add one or more additional amino acids at the C-terminus (e.g., 1, 2, 3, 4, 5, 6 or more additional amino acids) to any of the variants shown in Tables 1 and 2 (e.g., SEQ ID NOs: 1-70 (e.g., SEQ ID NOs: 6-70)). The C-terminal extension may correspond to sequence from the same position in wild-type ActRIIA. One potential C-terminal extension that can be included in the ActRIIA variants of the invention is amino acid sequence NP. For example, a sequence including the C-terminal extension NP is SEQ ID NO: 71 (e.g., SEQ ID NO: 69 with a C-terminal extension of NP). Another exemplary C-terminal extension that can be included in the ActRIIA variants of the invention is amino acid sequence NPVTPK (SEQ ID NO: 154). For example, a sequence including the C-terminal extension NPVTPK (SEQ ID NO: 154) is SEQ ID NO: 72 (e.g., SEQ ID NO: 69 with a C-terminal extension of NPVTPK (SEQ ID NO: 154)).

TABLE 1 Amino acid substitutions in an extracellular  ActRIIA variant having a sequence of any one  of SEQ ID NOs: 1-5 GAILGRSETQECLX₁X₂NANWX₃X₄X₅X₆TNQTGVEX₇CX₈GX₉X₁₀X₁₁ X₁₂X₁₃X₁₄HCX₁₅ATWX₁₆NISGSIEIVX₁₇X₁₈GCX₁₉X₂₀X₂₁DX₂₂ NCYDRTDCVEX₂₃X₂₄X₂₅X₂₆PX₂₇VYFCCCEGNMCNEKFSYFPEMEVT QPTS (SEQ ID NO: 1) GAILGRSETQECLFX₂NANWX₃X₄X₅X₆TNQTGVEX₇CX₈GX₉KX₁₁X₁₂ X₁₃X₁₄HCX₁₅ATWX₁₆NISGSIEIVX₁₇X₁₈GCX₁₉X₂₀X₂₁DX₂₂NCY DRTDCVEX₂₃X₂₄X₂₅X₂₆PX₂₇VYFCCCEGNMCNEKFSYFPEMEVTQPT S (SEQ ID NO: 2) GAILGRSETQECLFX₂NANWEX₄X₅RTNQTGVEX₇CX₈GX₉KDKRX₁₄ HCX₁₅ATWX₁₆NISGSIEIVKX₁₈GCWLDDX₂₂NCYDRTDCVEX₂₃ X₂₄X₂₅X₂₆PX₂₇VYFCCCEGNMCNEKFSYFPEMEVTQPTS  (SEQ ID NO: 3) GAILGRSETQECLFX₂NANWEX₄DRTNQTGVEX₇CX₈GX₉KDKRX₁₄ HCX₁₅ATWX₁₆NISGSIEIVKX₁₈GCWLDDX₂₂NCYDRTDCVEX₂₃ KX₂₅X₂₆PX₂₇VYFCCCEGNMCNEKFSYFPEMEVTQPTS  (SEQ ID NO: 4) GAILGRSETQECLFX₂NANWEX₄DRTNQTGVEPCX₈GX₉KDKRX₁₄ HCFATWKNISGSIEIVKX₁₈GCWLDDINCYDRTDCVEX₂₃KX₂₅X₂₆ PX₂₇VYFCCCEGNMCNEKFSYFPEMEVTQPTS  (SEQ ID NO: 5) GAILGRSETQECLX₁X₂NANWX₃X₄X₅X₆TNQTGVEX₇CX₈GX₉X₁₀X₁₁ X₁₂X₁₃X₁₄HCX₁₅ATWX₁₆NISGSIEIVX₁₇X₁₈GCX₁₉X₂₀X₂₁DX₂₂ NCYDRTDCVEX₂₃X₂₄X₂₅X₂₆PX₂₇VYFCCCEGNMCNEKFSYFPEMEVT QPTS (SEQ ID NO: 1) GAILGRSETQECLFX₂NANWX₃X₄X₅X₆TNQTGVEX₇CX₈GX₉KX₁₁X₁₂ X₁₃X₁₄HCX₁₅ATWX₁₆NISGSIEIVX₁₇X₁₈GCX₁₉X₂₀X₂₁DX₂₂NCY DRTDCVEX₂₃X₂₄X₂₅X₂₆PX₂₇VYFCCCEGNMCNEKFSYFPEMEVTQPT S (SEQ ID NO: 2) GAILGRSETQECLFX₂NANWEX₄X₅RTNQTGVEX₇CX₈GX₉KDKRX₁₄ HCX₁₅ATWX₁₆NISGSIEIVKX₁₈GCWLDDX₂₂NCYDRTDCVEX₂₃ X₂₄X₂₅X₂₆PX₂₇VYFCCCEGNMCNEKFSYFPEMEVTQPTS  (SEQ ID NO: 3) GAILGRSETQECLFX₂NANWEX₄DRTNQTGVEX₇CX₈GX₉KDKRX₁₄ HCX₁₅ATWX₁₆NISGSIEIVKX₁₈GCWLDDX₂₂NCYDRTDCVEX₂₃ KX₂₅X₂₆PX₂₇VYFCCCEGNMCNEKFSYFPEMEVTQPTS  (SEQ ID NO: 4) GAILGRSETQECLFX₂NANWEX₄DRTNQTGVEPCX₈GX₉KDKRX₁₄ HCFATWKNISGSIEIVKX₁₈GCWLDDINCYDRTDCVEX₂₃KX₂₅X₂₆ PX₂₇VYFCCCEGNMCNEKFSYFPEMEVTQPTS  (SEQ ID NO: 5) X₁ F or Y X₂ F or Y X₃ E or A X₄ K or L X₅ D or E X₆ R or A X₇ P or R X₈ Y or E X₉ D or E X₁₀ K or Q X₁₁ D or A X₁₂ K or A X₁₃ R or A X₁₄ R or L X₁₅ F or Y X₁₆ K, R, or A X₁₇ K, A, Y, F, or I X₁₈ Q or K X₁₉ W or A X₂₀ L or A X₂₁ D, K, R, A, F, G, M, N, or I X₂₂ I, F, or A X₂₃ K or T X₂₄ K or E X₂₅ D or E X₂₆ S or N X₂₇ E or Q

In some embodiments of the extracellular ActRIIA variant having the sequence of SEQ ID NO: 1 or 2, X₃ is E, X₆ is R, X₁₁ is D, X₁₂ is K, X₁₃ is R, X₁₆ is K or R, X₁₇ is K, X₁₉ is W, X₂₀ is L, X₂₁ is D, and X₂₂ is I or F. In some embodiments of the extracellular ActRIIA variant having the sequence of SEQ ID NO: 1, X₂ is Y; X₄ is L; X₈ is E; X₉ is E; X₁₄ is L; X₁₈ is K; X₂₃ is T; X₂₅ is E; X₂₆ is N; and X₂₇ is Q. These substitutions in SEQ ID NO: 1 can also be made in SEQ ID NOs: 2-5. In some embodiments of the extracellular ActRIIA variant having the sequence of SEQ ID NO: 1, X₁ is F or Y; X₂ is Y; X₄ is L; X₅ is D or E; X₇ is P or R; X₈ is E; X₉ is E; X₁₀ is K or Q; X₁₄ is L; X₁₅ is F or Y; X₁₆ is K or R; X₁₈ is K; X₂₂ is I or F; X₂₃ is T; X₂₄ is K or E; X₂₅ is E; X₂₆ is N; and X₂₇ is Q. In some embodiments of the extracellular ActRIIA variant having the sequence of SEQ ID NO: 1, X₁ is F or Y; X₂ is Y; X₃ is E; X₄ is L; X₅ is D or E; X₆ is R; X₇ is P or R; X₈ is E; X₉ is E; X₁₀ is K or Q; X₁₁ is D; X₁₂ is K; X₁₃ is R; X₁₄ is L; X₁₅ is F or Y; X₁₆ is K or R; X₁₇ is K; X₁₈ is K; X₁₉ is W; X₂₀ is L; X₂₁ is D; X₂₂ is I or F; X₂₃ is T; X₂₄ is K or E; X₂₅ is E; X₂₆ is N; and X₂₇ is Q. In some embodiments of the extracellular ActRIIA variant having the sequence of SEQ ID NO: 1 or 2, X₁₇ is K. In some embodiments of the extracellular ActRIIA variant having the sequence of SEQ ID NOs: 1-3, X₁₇ is K, X₂₃ is T, X₂₄ is E, X₂₅ is E, and X₂₆ is N. In some embodiments of the extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-5, X₁₇ is K, X₂₃ is T, X₂₄ is K, X₂₅ is E, and X₂₆ is N.

In some embodiments, a polypeptide described herein includes an extracellular ActRIIA variant having a sequence of any one of SEQ ID NOs: 6-72 (Table 2).

TABLE 2 Extracellular ActRIIA variants having the sequences of  SEQ ID NOs: 6-72 SEQ ID NO Amino Acid Sequence  6 GAILGRSETQECLFYNANWELDRTNQTGVEPCEGEKDKRLHCFATWKNISGSIEIVKKGCWL DDINCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS  7 GAILGRSETQECLFYNANWELERTNQTGVEPCEGEKDKRLHCFATWKNISGSIEIVKKGCWL DDINCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS  8 GAILGRSETQECLFYNANWELDRTNQTGVERCEGEKDKRLHCFATWKNISGSIEIVKKGCWL DDINCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS  9 GAILGRSETQECLFYNANWELDRTNQTGVEPCEGEKDKRLHCYATWKNISGSIEIVKKGCWL DDINCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 10 GAILGRSETQECLFYNANWELDRTNQTGVERCEGEKDKRLHCFATWRNISGSIEIVKKGCWL DDINCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 11 GAILGRSETQECLFYNANWELDRTNQTGVEPCEGEKDKRLHCFATWKNISGSIEIVKKGCWL DDFNCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 12 GAILGRSETQECLFYNANWELDRTNQTGVEPCEGEKDKRLHCFATWKNISGSIEIVKKGCWL DDINCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 13 GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCFATWKNISGSIEIVKKGCWL DDINCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 14 GAILGRSETQECLFYNANWELERTNQTGVEPCEGEKDKRLHCYATWKNISGSIEIVKKGCWL DDINCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 15 GAILGRSETQECLFYNANWELERTNQTGVEPCEGEKDKRLHCFATWRNISGSIEIVKKGCWL DDINCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 16 GAILGRSETQECLFYNANWELERTNQTGVEPCEGEKDKRLHCFATWKNISGSIEIVKKGCWL DDFNCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 17 GAILGRSETQECLFYNANWELERTNQTGVEPCEGEKDKRLHCFATWKNISGSIEIVKKGCWL DDINCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 18 GAILGRSETQECLFYNANWELDRTNQTGVERCEGEKDKRLHCYATWKNISGSIEIVKKGCWL DDINCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 19 GAILGRSETQECLFYNANWELDRTNQTGVERCEGEKDKRLHCFATWRNISGSIEIVKKGCWL DDINCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 20 GAILGRSETQECLFYNANWELDRTNQTGVERCEGEKDKRLHCFATWKNISGSIEIVKKGCWL DDFNCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 21 GAILGRSETQECLFYNANWELDRTNQTGVERCEGEKDKRLHCFATWKNISGSIEIVKKGCWL DDINCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 22 GAILGRSETQECLFYNANWELDRTNQTGVEPCEGEKDKRLHCYATWRNISGSIEIVKKGCWL DDINCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 23 GAILGRSETQECLFYNANWELDRTNQTGVEPCEGEKDKRLHCYATWKNISGSIEIVKKGCWL DDFNCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 24 GAILGRSETQECLFYNANWELDRTNQTGVEPCEGEKDKRLHCYATWKNISGSIEIVKKGCWL DDINCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 25 GAILGRSETQECLFYNANWELDRTNQTGVEPCEGEKDKRLHCFATWRNISGSIEIVKKGCWL DDFNCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 26 GAILGRSETQECLFYNANWELDRTNQTGVEPCEGEKDKRLHCFATWRNISGSIEIVKKGCWL DDINCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 27 GAILGRSETQECLFYNANWELDRTNQTGVEPCEGEKDKRLHCFATWKNISGSIEIVKKGCWL DDFNCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 28 GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCYATWKNISGSIEIVKKGCWL DDINCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 29 GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCFATWRNISGSIEIVKKGCWL DDINCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 30 GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCFATWKNISGSIEIVKKGCWL DDFNCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 31 GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCFATWKNISGSIEIVKKGCWL DDINCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 32 GAILGRSETQECLFYNANWELERTNQTGVEPCEGEKDKRLHCYATWRNISGSIEIVKKGCWL DDINCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 33 GAILGRSETQECLFYNANWELERTNQTGVEPCEGEKDKRLHCYATWKNISGSIEIVKKGCWL DDFNCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 34 GAILGRSETQECLFYNANWELERTNQTGVEPCEGEKDKRLHCYATWKNISGSISIVKKGCWL DDINCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 35 GAILGRSETQECLFYNANWELERTNQTGVEPCEGEKDKRLHCFATWRNISGSIEIVKKGCWL DDFNCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 36 GAILGRSETQECLFYNANWELERTNQTGVEPCEGEKDKRLHCFATWRNISGSIEIVKKGCWL DDINCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 37 GAILGRSETQECLFYNANWELERTNQTGVEPCEGEKDKRLHCFATWKNISGSIEIVKKGCWL DDFNCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 38 GAILGRSETQECLFYNANWELDRTNQTGVERCEGEKDKRLHCYATWRNISGSIEIVKKGCWL DDINCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 39 GAILGRSETQECLFYNANWELDRTNQTGVERCEGEKDKRLHCYATWKNISGSIEIVKKGCWL DDFNCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 40 GAILGRSETQECLFYNANWELDRTNQTGVERCEGEKDKRLHCYATWKNISGSIEIVKKGCWL DDINCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 41 GAILGRSETQECLFYNANWELDRTNQTGVERCEGEKDKRLHCFATWRNISGSIEIVKKGCWL DDFNCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 42 GAILGRSETQECLFYNANWELDRTNQTGVERCEGEKDKRLHCFATWRNISGSIEIVKKGCWL DDINCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 43 GAILGRSETQECLFYNANWELDRTNQTGVERCEGEKDKRLHCFATWKNISGSIEIVKKGC WLDDFNCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 44 GAILGRSETQECLFYNANWELDRTNQTGVEPCEGEKDKRLHCYATWRNISGSIEIVKKGCWL DDFNCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 45 GAILGRSETQECLFYNANWELDRTNQTGVEPCEGEKDKRLHCYATWRNISGSIEIVKKGCWL DDINCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 46 GAILGRSETQECLFYNANWELDRTNQTGVEPCEGEKDKRLHCYATWKNISGSIEIVKKGCWL DDFNCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 47 GAILGRSETQECLFYNANWELDRTNQTGVEPCEGEKDKRLHCFATWRNISGSIEIVKKGCWL DDFNCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 48 GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCYATWRNISGSIEIVKKGCWL DDINCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 49 GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCYATWKNISGSIEIVKKGCWL DDFNCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 50 GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCYATWKNISGSIEIVKKGCWL DDINCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 51 GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCFATWRNISGSIEIVKKGCWL DDFNCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 52 GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCFATWRNISGSIEIVKKGCWL DDINCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 53 GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCFATWKNISGSIEIVKKGCWL DDFNCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 54 GAILGRSETQECLFYNANWELERTNQTGVEPCEGEKDKRLHCYATWRNISGSIEIVKKGCWL DDFNCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 55 GAILGRSETQECLFYNANWELERTNQTGVEPCEGEKDKRLHCYATWRNISGSIEIVKKGCWL DDINCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 56 GAILGRSETQECLFYNANWELERTNQTGVEPCEGEKDKRLHCYATWKNISGSIEIVKKGCWL DDFNCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 57 GAILGRSETQECLFYNANWELERTNQTGVEPCEGEKDKRLHCFATWRNISGSIEIVKKGCWL DDFNCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 58 GAILGRSETQECLFYNANWELDRTNQTGVERCEGEKDKRLHCYATWRNISGSIEIVKKGCWL DDFNCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 59 GAILGRSETQECLFYNANWELDRTNQTGVERCEGEKDKRLHCYATWRNISGSIEIVKKGCWL DDINCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 60 GAILGRSETQECLFYNANWELDRTNQTGVERCEGEKDKRLHCYATWKNISGSIEIVKKGCWL DDFNCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 61 GAILGRSETQECLFYNANWELDRTNQTGVERCEGEKDKRLHCFATWRNISGSIEIVKKGCWL DDFNCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 62 GAILGRSETQECLFYNANWELDRTNQTGVEPCEGEKDKRLHCYATWRNISGSIEIVKKGCWL DDFNCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 63 GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCYATWRNISGSIEIVKKGCWL DDFNCYDRTDCVETKENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 64 GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCYATWRNISGSIEIVKKGCWL DDINCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 65 GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCYATWKNISGSIEIVKKGCWL DDFNCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 66 GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCFATWRNISGSIEIVKKGCWL DDFNCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 67 GAILGRSETQECLFYNANWELDRTNQTGVERCEGEKDKRLHCYATWRNISGSIEIVKKGCWL DDFNCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 68 GAILGRSETQECLFYNANWELERTNQTGVEPCEGEKDKRLHCYATWRNISGSIEIVKKGCWL DDFNCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 69 GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCYATWRNISGSIEIVKKGCWL DDFNCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 70 GAILGRSETQECLYYNANWELERTNQTGVERCEGEQDKRLHCYATWRNISGSIEIVKKGCWL DDFNCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS 71 GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCYATWRNISGSIEIVKKGCWL DDFNCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTSNP 72 GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCYATWRNISGSIEIVKKGCWL DDFNCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTSNPVTPK

In some embodiments, a polypeptide of the invention including an extracellular ActRIIA variant (e.g., any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) has amino acid K at position X₁₇. Altering the amino acid at position X₁₇ can result in reduced activity. For example, an ActRIIA variant having the sequence

GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCYATWRNISGSIEIVAKGCWLDDFNCYD RTDCVETEENPQVYFCCCEGNMCNEKFSYFPEMEVTQPTS (SEQ ID NO: 149) has reduced activity in vivo, indicating that the substitution of A for K at X₁₇ is not tolerated.

In some embodiments, a polypeptide of the invention including an extracellular ActRIIA variant (e.g., any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) with the sequence TEEN (SEQ ID NO: 161) at positions X₂₃, X₂₄, X₂₅, and X₂₆ can have a substitution of the amino acid K for the amino acid E at position X₂₄. In some embodiments, a polypeptide of the invention including an extracellular ActRIIA variant (e.g., any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) with the sequence TKEN (SEQ ID NO: 162) at positions X₂₃, X₂₄, X₂₅, and X₂₆ can have a substitution of the amino acid E for the amino acid K at position X₂₄. Polypeptides having the sequence TEEN (SEQ ID NO: 161) or TKEN (SEQ ID NO: 162) at positions X₂₃, X₂₄, X₂₅, and X₂₆ have reduced or weak binding to BMP9 (e.g., reduced binding to BMP9 compared to BMP9 binding of wild-type ActRIIA).

In some embodiments, a polypeptide of the invention including an extracellular ActRIIA variant (e.g., any one of SEQ ID NOs: 1-70 (e.g., SEQ ID NOs: 6-70)) may further include a C-terminal extension (e.g., one more additional amino acids at the C-terminus). The C-terminal extension may correspond to sequence from the same position in wild-type ActRIIA. In some embodiments, the C-terminal extension is amino acid sequence NP. For example, a sequence including the C-terminal extension NP is SEQ ID NO: 71 (e.g., SEQ ID NO: 69 with a C-terminal extension of NP). In some embodiments, the C-terminal extension is amino acid sequence NPVTPK (SEQ ID NO: 154). For example, a sequence including the C-terminal extension NPVTPK (SEQ ID NO: 154) is SEQ ID NO: 72 (e.g., SEQ ID NO: 69 with a C-terminal extension of NPVTPK (SEQ ID NO: 154)). The C-terminal extension can add one or more amino acids at the C-terminus (e.g., 1, 2, 3, 4, 5, 6 or more additional amino acids).

In some embodiments, a polypeptide of the invention including an extracellular ActRIIA variant may further include a moiety (e.g., Fc domain monomer, a wild-type Fc domain, an Fc domain with amino acid substitutions (e.g., one or more substitutions that reduce dimerization), an albumin-binding peptide, a fibronectin domain, or a human serum albumin), which may be fused to the N- or C-terminus (e.g., C-terminus) of the extracellular ActRIIA variant by way of a linker or other covalent bonds. A polypeptide including an extracellular ActRIIA variant fused to an Fc domain monomer may form a dimer (e.g., homodimer or heterodimer) through the interaction between two Fc domain monomers, which combine to form an Fc domain in the dimer.

In some embodiments, an extracellular ActRIIA variant described herein does not have the sequence of any one of SEQ ID NOs: 76-96 shown in Table 3 below.

TABLE 3 Excluded Extracellular ActRIIA Variants. SEQ  ID  NO Amino Acid Sequence 76 GAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFAT WANISGSIEIVKQGCWLDDINCYDRTDCVEKKDSPEVYFCCCEGN FMCNEKSYFPEMEVTQPTS 77 GAILGRSETQECLFFNANWAKDRTNQTGVEPCYGDKDKRRHCFAT WKNISGSIEIVKQGCWLDDINCYDRTDCVEKKDSPEVYFCCCEGN MCNEKFSYFPEMEVTQPTS 78 GAILGRSETQECLFFNANWEKDATNQTGVEPCYGDKDKRRHCFAT WKNISGSIEIVKQGCWLDDINCYDRTDCVEKKDSPEVYFCCCEGN MCNEKFSYFPEMEVTQPTS 79 GAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKAKRRHCFAT WKNISGSIEIVKQGCWLDDINCYDRTDCVEKKDSPEVYFCCCEGN MCNEKFSYFPEMEVTQPTS 80 GAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDARRHCFAT WKNISGSIEIVKQGCWLDDINCYDRTDCVEKKDSPEVYFCCCEGN MCNEKFSYFPEMEVTQPTS 81 GAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKARHCFAT WKNISGSIEIVKQGCWLDDINCYDRTDCVEKKDSPEVYFCCCEGN MCNEKFSYFPEMEVTQPTS 82 GAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFAT WKNISGSIEIVAQGCWLDDINCYDRTDCVEKKDSPEVYFCCCEGN MCNEKFSYFPEMEVTQPTS 83 GAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFAT WKNISGSIEIVYQGCWLDDINCYDRTDCVEKKDSPEVYFCCCEGN MCNEKFSYFPEMEVTQPTS 84 GAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFAT WKNISGSIEIVFQGCWLDDINCYDRTDCVEKKDSPEVYFCCCEGN MCNEKFSYFPEMEVTQPTS 85 GAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFAT WKNISGSIEIVIQGCWLDDINCYDRTDCVEKKDSPEVYFCCCEGN MCNEKFSYFPEMEVTQPTS 86 GAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFAT WKNISGSIEIVKQGCALDDINCYDRTDCVEKKDSPEVYFCCCEGN MCNEKFSYFPEMEVTQPTS 87 GAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFAT WKNISGSIEIVKQGCWADDINCYDRTDCVEKKDSPEVYFCCCEGN MCNEKFSYFPEMEVTQPTS 88 GAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFAT WKNISGSIEIVKQGCWLKDINCYDRTDCVEKKDSPEVYFCCCEGN MCNEKFSYFPEMEVTQPTS 89 GAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFAT WKNISGSIEIVKQGCWLRDINCYDRTDCVEKKDSPEVYFCCCEGN MCNEKFSYFPEMEVTQPTS 90 GAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFAT WKNISGSIEIVKQGCWLADINCYDRTDCVEKKDSPEVYFCCCEGN MCNEKFSYFPEMEVTQPTS 91 GAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFAT WKNISGSIEIVKQGCWLFDINCYDRTDCVEKKDSPEVYFCCCEGN MCNEKFSYFPEMEVTQPTS 92 GAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFAT WKNISGSIEIVKQGCWLGDINCYDRTDCVEKKDSPEVYFCCCEGN MCNEKFSYFPEMEVTQPTS 93 GAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFAT WKNISGSIEIVKQGCWLMDINCYDRTDCVEKKDSPEVYFCCCEGN MCNEKFSYFPEMEVTQPTS 94 GAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFAT WKNISGSIEIVKQGCWLNDINCYDRTDCVEKKDSPEVYFCCCEGN MCNEKFSYFPEMEVTQPTS 95 GAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFAT WKNISGSIEIVKQGCWLIDINCYDRTDCVEKKDSPEVYFCCCEGN MCNEKFSYFPEMEVTQPTS 96 GAILGRSETQECLFFNANWEKDRTNQTGVEPCYGDKDKRRHCFAT WKNISGSIEIVKQGCWLDDANCYDRTDCVEKKDSPEVYFCCCEGN MCNEKFSYFPEMEVTQPTS

Furthermore, in some embodiments, a polypeptide described herein (e.g., an ActRIIA variant-Fc fusion protein) has a serum half-life of at least 7 days in humans. The polypeptide may bind to activin A with a K_(D) of 10 pM or higher. In some embodiments, the polypeptide does not bind to BMP9 or activin A. In some embodiments, the polypeptide binds to activin A, activin B, and/or myostatin and exhibits reduced (e.g., weak) binding to BMP9 (e.g., reduced BMP9 binding compared to BMP9 binding of wild-type ActRIIA). In some embodiments, the polypeptide that has reduced or weak binding to BMP9 has the sequence TEEN (SEQ ID NO: 161) or TKEN (SEQ ID NO: 162) at positions X₂₃, X₂₄, X₂₅, and X₂₆. In some embodiments, the polypeptide does not substantially bind to human BMP9.

In some embodiments, the polypeptide may bind to human activin A with a K_(D) of about 800 pM or less (e.g., a K_(D) of about 800, 700, 600, 500, 400, 300, 200, 100, 90, 80, 70, 60, 50, 40, 30, 20, 10, 9, 8, 7, 6, 5, 4, 3, 2, or 1 pM or less, e.g., a K_(D) of between about 800 pM and about 200 pM). In some embodiments, the polypeptide may bind to human activin B with a K_(D) of 800 pM or less (e.g., a K_(D) of about 800, 700, 600, 500, 400, 300, 200, 100, 90, 80, 70, 60, 50, 40, 30, 20, 10, 9, 8, 7, 6, 5, 4, 3, 2, or 1 pM or less, e.g., a K_(D) of between about 800 pM and about 200 pM) The polypeptide may also bind to growth and differentiation factor 11 (GDF-11) with a K_(D) of approximately 5 pM or higher (e.g., a K_(D) of about 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, 80, 85, 90, 95, 100, 105, 110, 115, 120, 125, 130, 135, 140, 145, 150, 155, 160, 165, 170, 175, 180, 185, 190, 195, or 200 pM or higher).

II. Fc Domains

In some embodiments, a polypeptide described herein may include an extracellular ActRIIA variant fused to an Fc domain monomer of an immunoglobulin or a fragment of an Fc domain to increase the serum half-life of the polypeptide. A polypeptide including an extracellular ActRIIA variant fused to an Fc domain monomer may form a dimer (e.g., homodimer or heterodimer) through the interaction between two Fc domain monomers, which form an Fc domain in the dimer. As conventionally known in the art, an Fc domain is the protein structure that is found at the C-terminus of an immunoglobulin. An Fc domain includes two Fc domain monomers that are dimerized by the interaction between the C_(H)3 antibody constant domains. A wild-type Fc domain forms the minimum structure that binds to an Fc receptor, e.g., FcγRI, FcγRIIa, FcγRIIb, FcγRIIIa, FcγRIIIb, FcγRIV. In some embodiments, an Fc domain may be mutated to lack effector functions, typical of a “dead” Fc domain. For example, an Fc domain may include specific amino acid substitutions that are known to minimize the interaction between the Fc domain and an Fcγ receptor. In some embodiments, an Fc domain is from an IgG1 antibody and includes amino acid substitutions L234A, L235A, and G237A. In some embodiments, an Fc domain is from an IgG1 antibody and includes amino acid substitutions D265A, K322A, and N434A. The aforementioned amino acid positions are defined according to Kabat (Sequences of Proteins of Immunological Interest, 5th Ed. Public Health Service, National Institutes of Health, Bethesda, Md. (1991)). The Kabat numbering of amino acid residues may be determined for a given antibody by alignment at regions of homology of the sequence of the antibody with a “standard” Kabat numbered sequence. Furthermore, in some embodiments, an Fc domain does not induce any immune system-related response. For example, the Fc domain in a dimer of a polypeptide including an extracellular ActRIIA variant fused to an Fc domain monomer may be modified to reduce the interaction or binding between the Fc domain and an Fcγ receptor. The sequence of an Fc domain monomer that may be fused to an extracellular ActRIIA variant is shown below (SEQ ID NO: 97):

THTCPPCPAPELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHEDPE VKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYKCK VSNKALPVPIEKTISKAKGQPREPQVYTLPPSREEMTKNQVSLTCLVKGF YPSDIAVEWESNGQPENNYKTTPPVLDSDGPFFLYSKLTVDKSRWQQGNV FSCSVMHEALHNHYTQKSLSLSPGK

In some embodiments, an Fc domain is from an IgG1 antibody and includes amino acid substitutions L12A, L13A, and G15A, relative to the sequence of SEQ ID NO: 97. In some embodiments, an Fc domain is from an IgG1 antibody and includes amino acid substitutions D43A, K100A, and N212A, relative to the sequence of SEQ ID NO: 97. In some embodiments, the terminal lysine is absent from the Fc domain monomer having the sequence of SEQ ID NO: 97. In some embodiments, an extracellular ActRIIA variant described herein (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) may be fused to the N- or C-terminus of an Fc domain monomer (e.g., SEQ ID NO: 97) through conventional genetic or chemical means, e.g., chemical conjugation. If desired, a linker (e.g., a spacer) can be inserted between the extracellular ActRIIA variant and the Fc domain monomer. The Fc domain monomer can be fused to the N- or C-terminus (e.g., C-terminus) of the extracellular ActRIIA variant.

In some embodiments, a polypeptide described herein may include an extracellular ActRIIA variant fused to an Fc domain. In some embodiments, the Fc domain contains one or more amino acid substitutions that reduce or inhibit Fc domain dimerization. In some embodiments, the Fc domain contains a hinge domain. The Fc domain can be of immunoglobulin antibody isotype IgG, IgE, IgM, IgA, or IgD. Additionally, the Fc domain can be an IgG subtype (e.g., IgG1, IgG2a, IgG2b, IgG3, or IgG4). The Fc domain can also be a non-naturally occurring Fc domain, e.g., a recombinant Fc domain.

Methods of engineering Fc domains that have reduced dimerization are known in the art. In some embodiments, one or more amino acids with large side-chains (e.g., tyrosine or tryptophan) may be introduced to the C_(H)3-C_(H)3 dimer interface to hinder dimer formation due to steric clash. In other embodiments, one or more amino acids with small side-chains (e.g., alanine, valine, or threonine) may be introduced to the C_(H)3-C_(H)3 dimer interface to remove favorable interactions. Methods of introducing amino acids with large or small side-chains in the C_(H)3 domain are described in, e.g., Ying et al. (J Biol Chem. 287:19399-19408, 2012), U.S. Patent Publication No. 2006/0074225, U.S. Pat. Nos. 8,216,805 and 5,731,168, Ridgway et al. (Protein Eng. 9:617-612, 1996), Atwell et al. (J Mol Biol. 270:26-35, 1997), and Merchant et al. (Nat Biotechnol. 16:677-681, 1998), all of which are incorporated herein by reference in their entireties.

In yet other embodiments, one or more amino acid residues in the C_(H)3 domain that make up the C_(H)3-C_(H)3 interface between two Fc domains are replaced with positively-charged amino acid residues (e.g., lysine, arginine, or histidine) or negatively-charged amino acid residues (e.g., aspartic acid or glutamic acid) such that the interaction becomes electrostatically unfavorable depending on the specific charged amino acids introduced. Methods of introducing charged amino acids in the C_(H)3 domain to disfavor or prevent dimer formation are described in, e.g., Ying et al. (J Biol Chem. 287:19399-19408, 2012), U.S. Patent Publication Nos. 2006/0074225, 2012/0244578, and 2014/0024111, all of which are incorporated herein by reference in their entireties.

In some embodiments of the invention, an Fc domain includes one or more of the following amino acid substitutions: T366W, T366Y, T394W, F405W, Y349T, Y349E, Y349V, L351T, L351H, L351N, L352K, P353S, S354D, D356K, D356R, D356S, E357K, E357R, E357Q, S364A, T366E, L368T, L368Y, L368E, K370E, K370D, K370Q, K392E, K392D, T394N, P395N, P396T, V397T, V397Q, L398T, D399K, D399R, D399N, F405T, F405H, F405R, Y407T, Y407H, Y4071, K409E, K409D, K409T, and K409I, relative to the sequence of human IgG1. In some embodiments, the terminal lysine is absent from the Fc domain amino acid sequence. In one particular embodiment, an Fc domain includes the amino acid substitution T366W, relative to the sequence of human IgG1. The sequence of a wild-type Fc domain is shown below in SEQ ID NO: 150:

DKTHTCPPCPAPELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHED PEVKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYK CKVSNKALPAPIEKTISKAKGQPREPQVYTLPPSRDELTKNQVSLTCLVK GFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQG NVFSCSVMHEALHNHYTQKSLSLSPGK. An exemplary sequence for a wild-type Fc domain lacking the terminal lysine is provided below (SEQ ID NO: 155):

DKTHTCPPCPAPELLGGPSVFLFPPKPKDTLMISRTPEVTCVVVDVSHED PEVKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTVLHQDWLNGKEYK CKVSNKALPAPIEKTISKAKGQPREPQVYTLPPSRDELTKNQVSLTCLVK GFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYSKLTVDKSRWQQG NVFSCSVMHEALHNHYTQKSLSLSPG.

III. Albumin-Binding Peptide

In some embodiments, a polypeptide described herein may include an extracellular ActRIIA variant fused to a serum protein-binding peptide. Binding to serum protein peptides can improve the pharmacokinetics of protein pharmaceuticals.

As one example, albumin-binding peptides that can be used in the methods and compositions described here are generally known in the art. In one embodiment, the albumin binding peptide includes the sequence DICLPRWGCLW (SEQ ID NO: 151).

In the present invention, albumin-binding peptides may be joined to the N- or C-terminus (e.g., C-terminus) of an extracellular ActRIIA variant described herein (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) to increase the serum half-life of the extracellular ActRIIA variant. In some embodiments, an albumin-binding peptide is joined, either directly or through a linker, to the N- or C-terminus of an extracellular ActRIIA variant.

In some embodiments, an extracellular ActRIIA variant described herein (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) may be fused to the N- or C-terminus of albumin-binding peptide (e.g., SEQ ID NO: 151) through conventional genetic or chemical means, e.g., chemical conjugation. If desired, a linker (e.g., a spacer) can be inserted between the extracellular ActRIIA variant and the albumin-binding peptide. Without being bound to a theory, it is expected that inclusion of an albumin-binding peptide in an extracellular ActRIIA variant described herein may lead to prolonged retention of the therapeutic protein through its binding to serum albumin.

IV. Fibronectin Domain

In some embodiments, a polypeptide described herein may include an extracellular ActRIIA variant fused to fibronectin domains. Binding to fibronectin domains can improve the pharmacokinetics of protein pharmaceuticals.

Fibronectin domain is a high molecular weight glycoprotein of the extracellular matrix, or a fragment thereof, that binds to, e.g., membrane-spanning receptor proteins such as integrins and extracellular matrix components such as collagens and fibrins. In some embodiments of the present invention, a fibronectin domain is joined to the N- or C-terminus (e.g., C-terminus) of an extracellular ActRIIA variant described herein (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) to increase the serum half-life of the extracellular ActRIIA variant. A fibronectin domain can be joined, either directly or through a linker, to the N- or C-terminus of an extracellular ActRIIA variant.

As one example, fibronectin domains that can be used in the methods and compositions described here are generally known in the art. In one embodiment, the fibronectin domain is a fibronectin type III domain (SEQ ID NO: 152, below) having amino acids 610-702 of the sequence of UniProt ID NO: P02751.

GPVEVFITETPSQPNSHPIQWNAPQPSHISKYILRWRPKNSVGRWKEATI PGHLNSYTIKGLKPGVVYEGQLISIQQYGHQEVTRFDFTTTST

In another embodiment, the fibronectin domain is an adnectin protein.

In some embodiments, an extracellular ActRIIA variant described herein (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) may be fused to the N- or C-terminus of a fibronectin domain (e.g., SEQ ID NO: 152) through conventional genetic or chemical means, e.g., chemical conjugation. If desired, a linker (e.g., a spacer) can be inserted between the extracellular ActRIIA variant and the fibronectin domain. Without being bound to a theory, it is expected that inclusion of a fibronectin domain in an extracellular ActRIIA variant described herein may lead to prolonged retention of the therapeutic protein through its binding to integrins and extracellular matrix components such as collagens and fibrins.

V. Serum Albumin

In some embodiments, a polypeptide described herein may include an extracellular ActRIIA variant fused to serum albumin. Binding to serum albumins can improve the pharmacokinetics of protein pharmaceuticals.

Serum albumin is a globular protein that is the most abundant blood protein in mammals. Serum albumin is produced in the liver and constitutes about half of the blood serum proteins. It is monomeric and soluble in the blood. Some of the most crucial functions of serum albumin include transporting hormones, fatty acids, and other proteins in the body, buffering pH, and maintaining osmotic pressure needed for proper distribution of bodily fluids between blood vessels and body tissues. In preferred embodiments, serum albumin is human serum albumin. In some embodiments of the present invention, a human serum albumin is joined to the N- or C-terminus (e.g., C-terminus) of an extracellular ActRIIA variant described herein (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) to increase the serum half-life of the extracellular ActRIIA variant. A human serum albumin can be joined, either directly or through a linker, to the N- or C-terminus of an extracellular ActRIIA variant.

As one example, serum albumins that can be used in the methods and compositions described herein are generally known in the art. In one embodiment, the serum albumin includes the sequence of UniProt ID NO: P02768 (SEQ ID NO: 153, below).

MKWVTFISLLFLFSSAYSRGVFRRDAHKSEVAHRFKDLGEENFKALVLIA FAQYLQQCPFEDHVKLVNEVTEFAKTCVADESAENCDKSLHTLFGDKLCT VATLRETYGEMADCCAKQEPERNECFLQHKDDNPNLPRLVRPEVDVMCTA FHDNEETFLKKYLYEIARRHPYFYAPELLFFAKRYKAAFTECCQAADKAA CLLPKLDELRDEGKASSAKQRLKCASLQKFGERAFKAWAVARLSQRFPKA EFAEVSKLVTDLTKVHTECCHGDLLECADDRADLAKYICENQDSISSKLK ECCEKPLLEKSHCIAEVENDEMPADLPSLAADFVESKDVCKNYAEAKDVF LGMFLYEYARRHPDYSVVLLLRLAKTYETTLEKCCAAADPHECYAKVFDE FKPLVEEPQNLIKQNCELFEQLGEYKFQNALLVRYTKKVPQVSTPTLVEV SRNLGKVGSKCCKHPEAKRMPCAEDYLSVVLNQLCVLHEKTPVSDRVTKC CTESLVNRRPCFSALEVDETYVPKEFNAETFTFHADICTLSEKERQIKKQ TALVELVKHKPKATKEQLKAVMDDFAAFVEKCCKADDKETCFAEEGKKLV AASQAALGL

In some embodiments, an extracellular ActRIIA variant described herein (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) may be fused to the N- or C-terminus of a human serum albumin (e.g., SEQ ID NO: 153) through conventional genetic or chemical means, e.g., chemical conjugation. If desired, a linker (e.g., a spacer) can be inserted between the extracellular ActRIIA variant and the human serum albumin. Without being bound to a theory, it is expected that inclusion of a human serum albumin in an extracellular ActRIIA variant described herein may lead to prolonged retention of the therapeutic protein.

VI. Linkers

A polypeptide described herein may include an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having a sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) fused to a moiety by way of a linker. In some embodiments, the moiety increases stability of the polypeptide. Exemplary moieties include an Fc domain monomer, a wild-type Fc domain, an Fc domain with amino acid substitutions (e.g., one or more substitutions that reduce dimerization), an albumin-binding peptide, a fibronectin domain, or a human serum albumin. In the present invention, a linker between a moiety (e.g., an Fc domain monomer (e.g., the sequence of SEQ ID NO: 97), a wild-type Fc domain (e.g., SEQ ID NO: 150 or SEQ ID NO: 155), an Fc domain with amino acid substitutions (e.g., one or more substitutions that reduce dimerization), an albumin-binding peptide (e.g., SEQ ID NO: 151), a fibronectin domain (e.g., SEQ ID NO: 152), or a human serum albumin (e.g., SEQ ID NO: 153)) and an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), can be an amino acid spacer including 1-200 amino acids. Suitable peptide spacers are known in the art, and include, for example, peptide linkers containing flexible amino acid residues such as glycine, alanine, and serine. In some embodiments, a spacer can contain motifs, e.g., multiple or repeating motifs, of GA, GS, GG, GGA, GGS, GGG, GGGA (SEQ ID NO: 98), GGGS (SEQ ID NO: 99), GGGG (SEQ ID NO: 100), GGGGA (SEQ ID NO: 101), GGGGS (SEQ ID NO: 102), GGGGG (SEQ ID NO: 103), GGAG (SEQ ID NO: 104), GGSG (SEQ ID NO: 105), AGGG (SEQ ID NO: 106), or SGGG (SEQ ID NO: 107). In some embodiments, a spacer can contain 2 to 12 amino acids including motifs of GA or GS, e.g., GA, GS, GAGA (SEQ ID NO: 108), GSGS (SEQ ID NO: 109), GAGAGA (SEQ ID NO: 110), GSGSGS (SEQ ID NO: 111), GAGAGAGA (SEQ ID NO: 112), GSGSGSGS (SEQ ID NO: 113), GAGAGAGAGA (SEQ ID NO: 114), GSGSGSGSGS (SEQ ID NO: 115), GAGAGAGAGAGA (SEQ ID NO: 116), and GSGSGSGSGSGS (SEQ ID NO: 117). In some embodiments, a spacer can contain 3 to 12 amino acids including motifs of GGA or GGS, e.g., GGA, GGS, GGAGGA (SEQ ID NO: 118), GGSGGS (SEQ ID NO: 119), GGAGGAGGA (SEQ ID NO: 120), GGSGGSGGS (SEQ ID NO: 121), GGAGGAGGAGGA (SEQ ID NO: 122), and GGSGGSGGSGGS (SEQ ID NO: 123). In yet some embodiments, a spacer can contain 4 to 12 amino acids including motifs of GGAG (SEQ ID NO: 104), GGSG (SEQ ID NO: 105), e.g., GGAG (SEQ ID NO: 104), GGSG (SEQ ID NO: 105), GGAGGGAG (SEQ ID NO: 124), GGSGGGSG (SEQ ID NO: 125), GGAGGGAGGGAG (SEQ ID NO: 126), and GGSGGGSGGGSG (SEQ ID NO: 127). In some embodiments, a spacer can contain motifs of GGGGA (SEQ ID NO: 101) or GGGGS (SEQ ID NO: 102), e.g., GGGGAGGGGAGGGGA (SEQ ID NO: 128) and GGGGSGGGGSGGGGS (SEQ ID NO: 129). In some embodiments of the invention, an amino acid spacer between a moiety (e.g., an Fc domain monomer, a wild-type Fc domain, an Fc domain with amino acid substitutions (e.g., one or more substitutions that reduce dimerization), an albumin-binding peptide, a fibronectin domain, or a human serum albumin) and an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) may be GGG, GGGA (SEQ ID NO: 98), GGGG (SEQ ID NO: 100), GGGAG (SEQ ID NO: 130), GGGAGG (SEQ ID NO: 131), or GGGAGGG (SEQ ID NO: 132).

In some embodiments, a spacer can also contain amino acids other than glycine, alanine, and serine, e.g., AAAL (SEQ ID NO: 133), AAAK (SEQ ID NO: 134), AAAR (SEQ ID NO: 135), EGKSSGSGSESKST (SEQ ID NO: 136), GSAGSAAGSGEF (SEQ ID NO: 137), AEAAAKEAAAKA (SEQ ID NO: 138), KESGSVSSEQLAQFRSLD (SEQ ID NO: 139), GENLYFQSGG (SEQ ID NO: 140), SACYCELS (SEQ ID NO: 141), RSIAT (SEQ ID NO: 142), RPACKIPNDLKQKVMNH (SEQ ID NO: 143), GGSAGGSGSGSSGGSSGASGTGTAGGTGSGSGTGSG (SEQ ID NO: 144), AAANSSIDLISVPVDSR (SEQ ID NO: 145), or GGSGGGSEGGGSEGGGSEGGGSEGGGSEGGGSGGGS (SEQ ID NO: 146). In some embodiments, a spacer can contain motifs, e.g., multiple or repeating motifs, of EAAAK (SEQ ID NO: 147). In some embodiments, a spacer can contain motifs, e.g., multiple or repeating motifs, of proline-rich sequences such as (XP)_(n) (SEQ ID NO: 163), in which X may be any amino acid (e.g., A, K, or E) and n is from 1-5, and PAPAP (SEQ ID NO: 148).

The length of the peptide spacer and the amino acids used can be adjusted depending on the two proteins involved and the degree of flexibility desired in the final protein fusion polypeptide. The length of the spacer can be adjusted to ensure proper protein folding and avoid aggregate formation.

In some embodiments, the linker between a moiety (e.g., an Fc domain monomer (e.g., the sequence of SEQ ID NO: 97), a wild-type Fc domain (e.g., SEQ ID NO: 150 or SEQ ID NO: 155), an Fc domain with amino acid substitutions (e.g., one or more substitutions that reduce dimerization), an albumin-binding peptide (e.g., SEQ ID NO: 151), a fibronectin domain (e.g., SEQ ID NO: 152), or a human serum albumin (e.g., SEQ ID NO: 153)) and an extracellular ActRIIA variant described herein (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), is an amino acid spacer having the sequence GGG. For example, a polypeptide of the invention can contain an extracellular ActRIIA variant (e.g., any one of SEQ ID NOs: 6-72) fused to an Fc domain (e.g., SEQ ID NO: 155) by a GGG linker. An exemplary polypeptide containing an ActRIIA variant of SEQ ID NO: 69, a GGG linker, and an Fc domain lacking a terminal lysine (SEQ ID NO: 155) is provided below (SEQ ID NO: 156):

GAILGRSETQECLFYNANWELERTNQTGVERCEGEKDKRLHCYATWRNIS GSIEIVKKGCWLDDFNCYDRTDCVETEENPQVYFCCCEGNMCNEKFSYFP EMEVTQPTSGGGDKTHTCPPCPAPELLGGPSVFLFPPKPKDTLMISRTPE VTCVVVDVSHEDPEVKFNWYVDGVEVHNAKTKPREEQYNSTYRVVSVLTV LHQDWLNGKEYKCKVSNKALPAPIEKTISKAKGQPREPQVYTLPPSRDEL TKNQVSLTCLVKGFYPSDIAVEWESNGQPENNYKTTPPVLDSDGSFFLYS KLTVDKSRWQQGNVFSCSVMHEALHNHYTQKSLSLSPG

VII. Vectors, Host Cells, and Protein Production

The polypeptides of the invention can be produced from a host cell. A host cell refers to a vehicle that includes the necessary cellular components, e.g., organelles, needed to express the polypeptides and fusion polypeptides described herein from their corresponding nucleic acids. The nucleic acids may be included in nucleic acid vectors that can be introduced into the host cell by conventional techniques known in the art (e.g., transformation, transfection, electroporation, calcium phosphate precipitation, direct microinjection, infection, or the like). The choice of nucleic acid vectors depends in part on the host cells to be used. Generally, preferred host cells are of either eukaryotic (e.g., mammalian) or prokaryotic (e.g., bacterial) origin.

Nucleic Acid Vector Construction and Host Cells

A nucleic acid sequence encoding the amino acid sequence of a polypeptide of the invention may be prepared by a variety of methods known in the art. These methods include, but are not limited to, oligonucleotide-mediated (or site-directed) mutagenesis and PCR mutagenesis. A nucleic acid molecule encoding a polypeptide of the invention may be obtained using standard techniques, e.g., gene synthesis. Alternatively, a nucleic acid molecule encoding a wild-type extracellular ActRIIA may be mutated to include specific amino acid substitutions using standard techniques in the art, e.g., QuikChange™ mutagenesis. Nucleic acid molecules can be synthesized using a nucleotide synthesizer or PCR techniques.

A nucleic acid sequence encoding a polypeptide of the invention may be inserted into a vector capable of replicating and expressing the nucleic acid molecule in prokaryotic or eukaryotic host cells. Many vectors are available in the art and can be used for the purpose of the invention. Each vector may include various components that may be adjusted and optimized for compatibility with the particular host cell. For example, the vector components may include, but are not limited to, an origin of replication, a selection marker gene, a promoter, a ribosome binding site, a signal sequence, the nucleic acid sequence encoding protein of interest, and a transcription termination sequence.

In some embodiments, mammalian cells may be used as host cells for the invention. Examples of mammalian cell types include, but are not limited to, human embryonic kidney (HEK) (e.g., HEK293, HEK 293F), Chinese hamster ovary (CHO), HeLa, COS, PC3, Vero, MC3T3, NS0, Sp2/0, VERY, BHK, MDCK, W138, BT483, Hs578T, HTB2, BT20, T47D, NS0 (a murine myeloma cell line that does not endogenously produce any immunoglobulin chains), CRL7O3O, and HsS78Bst cells. In some embodiments, E. coli cells may also be used as host cells for the invention. Examples of E. coli strains include, but are not limited to, E. coli 294 (ATCC® 31,446), E. coli λ 1776 (ATCC® 31,537, E. coli BL21 (DE3) (ATCC® BAA-1025), and E. coli RV308 (ATCC® 31,608). Different host cells have characteristic and specific mechanisms for the posttranslational processing and modification of protein products (e.g., glycosylation). Appropriate cell lines or host systems may be chosen to ensure the correct modification and processing of the polypeptide expressed. The above-described expression vectors may be introduced into appropriate host cells using conventional techniques in the art, e.g., transformation, transfection, electroporation, calcium phosphate precipitation, and direct microinjection. Once the vectors are introduced into host cells for protein production, host cells are cultured in conventional nutrient media modified as appropriate for inducing promoters, selecting transformants, or amplifying the genes encoding the desired sequences. Methods for expression of therapeutic proteins are known in the art, see, for example, Paulina Balbas, Argelia Lorence (eds.) Recombinant Gene Expression: Reviews and Protocols (Methods in Molecular Biology), Humana Press; 2nd ed. 2004 and Vladimir Voynov and Justin A. Caravella (eds.) Therapeutic Proteins: Methods and Protocols (Methods in Molecular Biology) Humana Press; 2nd ed. 2012.

Protein Production, Recovery, and Purification

Host cells used to produce the polypeptides of the invention may be grown in media known in the art and suitable for culturing of the selected host cells. Examples of suitable media for mammalian host cells include Minimal Essential Medium (MEM), Dulbecco's Modified Eagle's Medium (DMEM), Expi293™ Expression Medium, DMEM with supplemented fetal bovine serum (FBS), and RPMI-1640. Examples of suitable media for bacterial host cells include Luria broth (LB) plus necessary supplements, such as a selection agent, e.g., ampicillin. Host cells are cultured at suitable temperatures, such as from about 20° C. to about 39° C., e.g., from 25° C. to about 37° C., preferably 37° C., and CO₂ levels, such as 5 to 10%. The pH of the medium is generally from about 6.8 to 7.4, e.g., 7.0, depending mainly on the host organism. If an inducible promoter is used in the expression vector of the invention, protein expression is induced under conditions suitable for the activation of the promoter.

In some embodiments, depending on the expression vector and the host cells used, the expressed protein may be secreted from the host cells (e.g., mammalian host cells) into the cell culture media. Protein recovery may involve filtering the cell culture media to remove cell debris. The proteins may be further purified. A polypeptide of the invention may be purified by any method known in the art of protein purification, for example, by chromatography (e.g., ion exchange, affinity, and size-exclusion column chromatography), centrifugation, differential solubility, or by any other standard technique for the purification of proteins. For example, the protein can be isolated and purified by appropriately selecting and combining affinity columns such as Protein A column (e.g., POROS Protein A chromatography) with chromatography columns (e.g., POROS HS-50 cation exchange chromatography), filtration, ultra filtration, salting-out and dialysis procedures.

In other embodiments, host cells may be disrupted, e.g., by osmotic shock, sonication, or lysis, to recover the expressed protein. Once the cells are disrupted, cell debris may be removed by centrifugation or filtration. In some instances, a polypeptide can be conjugated to marker sequences, such as a peptide to facilitate purification. An example of a marker amino acid sequence is a hexa-histidine peptide (SEQ ID NO: 164) (His-tag), which binds to nickel-functionalized agarose affinity column with micromolar affinity. Other peptide tags useful for purification include, but are not limited to, the hemagglutinin “HA” tag, which corresponds to an epitope derived from influenza hemagglutinin protein (Wilson et al., Cell 37:767, 1984).

Alternatively, the polypeptides of the invention can be produced by the cells of a subject (e.g., a human), e.g., in the context of gene therapy, by administrating a vector (such as a viral vector (e.g., a retroviral vector, adenoviral vector, poxviral vector (e.g., vaccinia viral vector, such as Modified Vaccinia Ankara (MVA)), adeno-associated viral vector, and alphaviral vector)) containing a nucleic acid molecule encoding the polypeptide of the invention. The vector, once inside a cell of the subject (e.g., by transformation, transfection, electroporation, calcium phosphate precipitation, direct microinjection, infection, etc.) will promote expression of the polypeptide, which is then secreted from the cell. If treatment of a disease or disorder is the desired outcome, no further action may be required. If collection of the protein is desired, blood may be collected from the subject and the protein purified from the blood by methods known in the art.

VIII. Pharmaceutical compositions and preparations

The invention features pharmaceutical compositions that include the polypeptides described herein (e.g., a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)). In some embodiments, a pharmaceutical composition of the invention includes a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-70 (e.g., SEQ ID NOs: 6-70)) with a C-terminal extension (e.g., 1, 2, 3, 4, 5, 6 or more additional amino acids) as the therapeutic protein. In some embodiments, a pharmaceutical composition of the invention includes a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) fused to a moiety (e.g., Fc domain monomer, or a dimer thereof, a wild-type Fc domain, an Fc domain with amino acid substitutions (e.g., one or more substitutions that reduce dimerization), an albumin-binding peptide, a fibronectin domain, or a human serum albumin) as the therapeutic protein. In some embodiments, a pharmaceutical composition of the invention including a polypeptide of the invention may be used in combination with other agents (e.g., therapeutic biologics and/or small molecules) or compositions in a therapy. In addition to a therapeutically effective amount of the polypeptide, the pharmaceutical composition may include one or more pharmaceutically acceptable carriers or excipients, which can be formulated by methods known to those skilled in the art. In some embodiments, a pharmaceutical composition of the invention includes a nucleic acid molecule (DNA or RNA, e.g., mRNA) encoding a polypeptide of the invention, or a vector containing such a nucleic acid molecule.

Acceptable carriers and excipients in the pharmaceutical compositions are nontoxic to recipients at the dosages and concentrations employed. Acceptable carriers and excipients may include buffers such as phosphate, citrate, HEPES, and TAE, antioxidants such as ascorbic acid and methionine, preservatives such as hexamethonium chloride, octadecyldimethylbenzyl ammonium chloride, resorcinol, and benzalkonium chloride, proteins such as human serum albumin, gelatin, dextran, and immunoglobulins, hydrophilic polymers such as polyvinylpyrrolidone, amino acids such as glycine, glutamine, histidine, arginine, and lysine, and carbohydrates such as glucose, mannose, sucrose, and sorbitol. Pharmaceutical compositions of the invention can be administered parenterally in the form of an injectable formulation. Pharmaceutical compositions for injection can be formulated using a sterile solution or any pharmaceutically acceptable liquid as a vehicle. Pharmaceutically acceptable vehicles include, but are not limited to, sterile water, physiological saline, and cell culture media (e.g., Dulbecco's Modified Eagle Medium (DMEM), α-Modified Eagles Medium (α-MEM), F-12 medium). Formulation methods are known in the art, see e.g., Banga (ed.) Therapeutic Peptides and Proteins: Formulation, Processing and Delivery Systems (3rd ed.) Taylor & Francis Group, CRC Press (2015).

The pharmaceutical compositions of the invention may be prepared in microcapsules, such as hydroxylmethylcellulose or gelatin-microcapsule and poly-(methylmethacrylate) microcapsule. The pharmaceutical compositions of the invention may also be prepared in other drug delivery systems such as liposomes, albumin microspheres, microemulsions, nanoparticles, and nanocapsules. Such techniques are described in Remington: The Science and Practice of Pharmacy 22^(nd) edition (2012). The pharmaceutical compositions to be used for in vivo administration must be sterile. This is readily accomplished by filtration through sterile filtration membranes.

The pharmaceutical compositions of the invention may also be prepared as a sustained-release formulation. Suitable examples of sustained-release preparations include semipermeable matrices of solid hydrophobic polymers containing the polypeptides of the invention. Examples of sustained release matrices include polyesters, hydrogels, polylactides, copolymers of L-glutamic acid and γ ethyl-L-glutamate, non-degradable ethylene-vinyl acetate, degradable lactic acid-glycolic acid copolymers such as LUPRON DEPOT™, and poly-D-(−)-3-hydroxybutyric acid. Some sustained-release formulations enable release of molecules over a few months, e.g., one to six months, while other formulations release pharmaceutical compositions of the invention for shorter time periods, e.g., days to weeks.

The pharmaceutical composition may be formed in a unit dose form as needed. The amount of active component, e.g., a polypeptide of the invention, included in the pharmaceutical preparations is such that a suitable dose within the designated range is provided (e.g., a dose within the range of 0.01-100 mg/kg of body weight).

The pharmaceutical composition for gene therapy can be in an acceptable diluent, or can include a slow release matrix in which the gene delivery vehicle is imbedded. If hydrodynamic injection is used as the delivery method, the pharmaceutical composition containing a nucleic acid molecule encoding a polypeptide described herein or a vector (e.g., a viral vector) containing the nucleic acid molecule is delivered rapidly in a large fluid volume intravenously. Vectors that may be used as in vivo gene delivery vehicle include, but are not limited to, retroviral vectors, adenoviral vectors, poxviral vectors (e.g., vaccinia viral vectors, such as Modified Vaccinia Ankara), adeno-associated viral vectors, and alphaviral vectors.

IX. Routes, Dosage, and Administration

Pharmaceutical compositions that include the polypeptides of the invention as the therapeutic proteins may be formulated for, e.g., intravenous administration, parenteral administration, subcutaneous administration, intramuscular administration, intra-arterial administration, intrathecal administration, or intraperitoneal administration. The pharmaceutical composition may also be formulated for, or administered via, oral, nasal, spray, aerosol, rectal, or vaginal administration. For injectable formulations, various effective pharmaceutical carriers are known in the art. See, e.g., ASHP Handbook on Injectable Drugs, Toissel, 18th ed. (2014).

In some embodiments, a pharmaceutical composition that includes a nucleic acid molecule encoding a polypeptide of the invention or a vector containing such nucleic acid molecule may be administered by way of gene delivery. Methods of gene delivery are well-known to one of skill in the art. Vectors that may be used for in vivo gene delivery and expression include, but are not limited to, retroviral vectors, adenoviral vectors, poxviral vectors (e.g., vaccinia viral vectors, such as Modified Vaccinia Ankara (MVA)), adeno-associated viral vectors, and alphaviral vectors. In some embodiments, mRNA molecules encoding polypeptides of the invention may be administered directly to a subject.

In some embodiments of the present invention, nucleic acid molecules encoding a polypeptide described herein or vectors containing such nucleic acid molecules may be administered using a hydrodynamic injection platform. In the hydrodynamic injection method, a nucleic acid molecule encoding a polypeptide described herein is put under the control of a strong promoter in an engineered plasmid (e.g., a viral plasmid). The plasmid is often delivered rapidly in a large fluid volume intravenously. Hydrodynamic injection uses controlled hydrodynamic pressure in veins to enhance cell permeability such that the elevated pressure from the rapid injection of the large fluid volume results in fluid and plasmid extravasation from the vein. The expression of the nucleic acid molecule is driven primarily by the liver. In mice, hydrodynamic injection is often performed by injection of the plasmid into the tail vein. In certain embodiments, mRNA molecules encoding a polypeptide described herein may be administered using hydrodynamic injection.

The dosage of the pharmaceutical compositions of the invention depends on factors including the route of administration, the disease to be treated, and physical characteristics, e.g., age, weight, general health, of the subject. A pharmaceutical composition of the invention may include a dosage of a polypeptide of the invention ranging from 0.01 to 500 mg/kg (e.g., 0.01, 0.1, 0.2, 0.3, 0.4, 0.5, 0.75, 1, 1.25, 1.5, 1.75, 2, 2.25, 2.5, 2.75, 3, 3.25, 3.5, 3.75, 4, 4.25, 4.5, 4.75, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 100, 150, 200, 250, 300, 350, 400, 450, or 500 mg/kg) and, in a more specific embodiment, about 0.1 to about 30 mg/kg and, in a more specific embodiment, about 0.3 to about 30 mg/kg. The dosage may be adapted by the physician in accordance with conventional factors such as the extent of the disease and different parameters of the subject.

The pharmaceutical compositions are administered in a manner compatible with the dosage formulation and in such amount as is therapeutically effective to result in an improvement or remediation of the symptoms. The pharmaceutical compositions are administered in a variety of dosage forms, e.g., intravenous dosage forms, subcutaneous dosage forms, and oral dosage forms (e.g., ingestible solutions, drug release capsules). Generally, therapeutic proteins are dosed at 0.1-100 mg/kg, e.g., 0.5-50 mg/kg. Pharmaceutical compositions that include a polypeptide of the invention may be administered to a subject in need thereof, for example, one or more times (e.g., 1-10 times or more) daily, weekly, biweekly, every four weeks, monthly, bimonthly, quarterly, biannually, annually, or as medically necessary. In some embodiments, pharmaceutical compositions that include a polypeptide of the invention may be administered to a subject in need thereof weekly, biweekly, every four weeks, monthly, bimonthly, or quarterly. Dosages may be provided in either a single or multiple dosage regimens. The timing between administrations may decrease as the medical condition improves or increase as the health of the patient declines.

X. Methods of Treatment

The invention is based on the discovery that substituting amino acids from the extracellular portion of ActRIIB into the extracellular portion ActRIIA yields ActRIIA variants with improved properties. The ActRIIA variants generated by introducing residues from ActRIIB into ActRIIA retain the beneficial properties of ActRIIA, such as low binding affinity to BMP9 and longer serum half-life as an Fc fusion protein, and gain some of the beneficial properties of ActRIIB, such as increased binding to activins A and B (see Table 5 in Example 1). These ActRIIA variant properties make for a useful therapeutic that can compete with endogenous activin receptors for ligand binding. As the ActRIIA variants contain the extracellular portion of the receptor, they will be soluble and able to bind to and sequester ligands (e.g., activins A and B, myostatin, GDF11) without activating intracellular signaling pathways. Therefore, the extracellular ActRIIA variants can be used to treat diseases or conditions in which elevated activin signaling has been implicated (e.g., associated with increased expression of activin receptors or activin receptor ligands). For example, myostatin has been implicated in promoting fibrosis, inhibiting skeletal muscle growth, and regulating bone homeostasis, and elevated myostatin has been observed in subcutaneous and visceral fat of obese mice and plasma of obese and insulin resistant women. In addition, activin A has been reported to be upregulated in bone disease, adipose tissue, and subcutaneous and visceral fat of obese mice, and has been found to inhibit osteoblast activity. Another activin receptor ligand, GDF11, has been found to be overexpressed in a mouse model of hemolytic anemia and associated with defects in red blood cell production, and both type I and type II activin receptors have been linked to pancreatic function and diabetes. Without wishing to be bound by theory, a therapeutic agent that binds to activin receptor ligands (e.g., myostatin, activins, and/or GDF11) and reduces their binding to or interaction with endogenous activin receptors (e.g., by sequestering the endogenous ligands) may have therapeutic utility for treating or preventing a variety of diseases or conditions, such as neuromuscular disease, osteogenesis imperfecta, myelofibrosis, myelodysplastic syndromes, thrombocytopenia, neutropenia, age-related metabolic disease, and treatment-related metabolic disease.

In some embodiments, the polypeptides described herein (e.g., a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), e.g., an effective amount of an ActRIIA variant) may be administered to increase platelet levels (e.g., increase platelet count), increase or induce megakaryocyte differentiation and/or maturation (e.g., to produce platelets), reduce platelet progenitor accumulation (e.g., by stimulating progenitor cells to progress to maturation), promote or increase platelet formation or production, improve blood clotting, reduce bleeding events, and/or reduce bleeding in the skin (e.g., petechiae or bruising) in a subject in need thereof. In some embodiments, the subject may have or be at risk of developing a disease or condition associated with low platelet levels (e.g., thrombocytopenia). The invention also includes methods of treating a subject having or at risk of developing (e.g., treating, delaying the development of, and/or preventing) thrombocytopenia by administering to the subject an effective amount of a polypeptide described herein (e.g., a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), e.g., an effective amount of an ActRIIA variant). In any of the methods described herein, a subject having or at risk of developing low platelet levels (e.g., low platelet counts) has or is at risk of developing thrombocytopenia. In some embodiments, a megakaryocyte can be contacted in vitro with a polypeptide described herein, a nucleic acid encoding the polypeptide, or a vector containing the nucleic acid to generate platelets for the treatment of thrombocytopenia. In some embodiments, the thrombocytopenia is associated with a bone marrow defect, a myelodysplastic syndrome, bone marrow transplantation, myelofibrosis, myelofibrosis treatment (e.g., treatment with a JAK inhibitor, such as with ruxolitinib or fedratinib), Gaucher disease, aplastic anemia, Fanconi anemia, Diamond Blackfan anemia, Shwachman Diamond syndrome, heavy alcohol consumption, cirrhosis of the liver, cancer (e.g., leukemia or lymphoma), an autoimmune disease (e.g., rheumatoid arthritis, lupus (e.g., SLE), antiphospholipid syndrome (APS), Evans syndrome, or immune thyroid disease), a viral infection (e.g., hepatitis C, HIV, chickenpox, mumps, rubella, parvovirus, or Epstein-Barr virus), a bacterial infection (e.g., bacteremia), an enlarged spleen, vitamin deficiency (e.g., vitamin B-12 deficiency, folate deficiency, or iron deficiency), cancer treatment (e.g., chemotherapy or radiation therapy), thrombotic thrombocytopenic purpura, idiopathic thrombocytopenic purpura, disseminated intravascular coagulation, hemolytic uremic syndrome, paroxysmal nocturnal hemoglobinuria, or a reduction of platelets caused by medication (medication-induced thrombocytopenia, e.g., thrombocytopenia caused by treatment with heparin, quinine, a sulfa-containing antibiotic, such as vancomycin, rifampin, or trimethoprim, or an anticonvulsant, such as phenytoin)), dilution of platelets caused by blood transfusion, hematopoietic stem cell transplantation, ineffective hematopoiesis, acquired amegakaryocytic thrombocytopenia, Pearson syndrome, dyskeratosis congenita, or contraindication to transfusion (e.g., patients of advanced age, patients with allo- or auto-antibodies, pediatric patients, patients with cardiopulmonary disease, patients who object to transfusion for religious reasons (e.g., some Jehovah's Witnesses)). The myelodysplastic syndrome may be myelodysplastic syndrome with unilineage dysplasia (MDS-SLD), myelodysplastic syndrome with multilineage dysplasia (MDS-MLD), myelodysplastic syndrome with ring sideroblasts (MDS-RS, which includes single lineage dysplasia (MDS-RS-SLD) and multilineage dysplasia (MDS-RS-MLD)), myelodysplastic syndrome associated with isolated del chromosome abnormality (MDS with isolated del(5q)), myelodysplastic syndrome with excess blasts (MDS-EB; which includes myelodysplastic syndrome with excess blasts—type 1 (MDS-EB-1) and myelodysplastic syndrome with excess blasts—type 2 (MDS-EB-2)), myelodysplastic syndrome, unclassifiable (MDS-U), or myelodysplastic syndrome/myeloproliferative neoplasm with ring sideroblasts and thrombocytosis (MDS/MPN-RS-T). The myelodysplastic syndrome may be a very low, low, or intermediate risk MDS as determined by the Revised International Prognostic Scoring System (IPSS-R). The myelodysplastic syndrome may be an RS-positive myelodysplastic syndrome (e.g., the subject with a myelodysplastic syndrome may have ring sideroblasts) or a non-RS myelodysplastic syndrome (e.g., the subject with a myelodysplastic syndrome may lack ring sideroblasts). In some embodiments, the RS-positive myelodysplastic syndrome is associated with a splicing factor mutation, such as a mutation in SF3B1. In some embodiments, the MDS is associated with a defect in terminal maturation (often observed in RS-positive MDS and in subjects having splicing factor mutations). In some embodiments, the MDS is associated with a defect in early-stage hematopoiesis (e.g., commitment or early differentiation). In some embodiments, the MDS is associated with elevated endogenous erythropoietin levels. In some embodiments, the myelodysplastic syndrome is associated with hypocellular bone marrow (e.g., the subject with MDS has hypocellular bone marrow). The subject may have a low transfusion burden or a high transfusion burden. In some embodiments, the subject has a low transfusion burden and received 1-3 RBC units in the eight weeks prior to treatment with an ActRIIA variant described herein. In some embodiments, the subject has a low transfusion burden and did not receive a transfusion (received 0 RBC units) in the eight weeks prior to treatment with an ActRIIA variant described herein. In some embodiments, the subject does not respond well to erythropoietin (EPO) or is susceptible to adverse effects of EPO (e.g., hypertension, headaches, vascular thrombosis, influenza-like syndrome, obstruction of shunts, and myocardial infarction). The compositions and methods described herein can also be used to treat subjects that do not respond to an erythroid maturation agent. In some embodiments, the subject has previously been treated with an ESA. In some embodiments, the subject has not previously been treated with an ESA. In some embodiments, the thrombocytopenia is familial thrombocytopenia (also referred to as inherited thrombocytopenia, e.g., thrombocytopenia associated with a genetic mutation, such as May-Hegglin anomaly, Sebastian syndrome, Fechtner syndrome, Epstein's syndrome, Wiskott-Aldrich syndrome, congenital amegakaryocytic thrombocytopenia, platelet storage pool deficiency, Hermansky-Pudlak syndrome, Bernard-Soulier syndrome, Von Willebrand Disease Type 2B, ANKRD26-related thrombocytopenia, thrombocytopenia absent radius syndrome, familial platelet disorder with associated myeloid malignancy (FPD/AML, associated with mutations in RUNX1), thrombocytopenia associated with a mutation in Filamin-A, or thrombocytopenia associated with a mutation in GATA1). In some embodiments, the thrombocytopenia is immune thrombocytopenia. In some embodiments, the methods described herein are directed to affecting myostatin, activin A, activin B, and/or BMP9 signaling (e.g., reducing or inhibiting the binding of activin A, activin B, myostatin, and/or BMP9 to their endogenous receptors, e.g., ActRIIA, ActRIIB, and/or BMPRII) in a subject having or at risk of developing a disease or condition involving low platelet levels (e.g., thrombocytopenia). In some embodiments, affecting myostatin, activin A, activin B, and/or BMP9 signaling results in an increase in the subject's platelet levels (e.g., an increase in platelet count, megakaryocyte differentiation and/or maturation, and/or platelet formation or production) or a reduction in the accumulation of platelet progenitor cells. In some embodiments, the methods described herein increase platelet levels (e.g., platelet counts), increase or induce megakaryocyte differentiation and/or maturation, promote or increase platelet formation or production, reduce the accumulation of platelet progenitor cells, improve blood clotting, reduce bleeding events (e.g., reduce the incidence of bleeding events), and/or reduce bleeding in the skin compared to measurements obtained prior to treatment or compared to measurements obtained from untreated subjects having the same disease or condition. In some embodiments, the subject is identified as having thrombocytopenia prior to treatment with an ActRIIA variant described herein. In some embodiments, the method includes a step of identifying the subject as having thrombocytopenia (e.g., by evaluating platelet levels) prior to treatment with an ActRIIA variant described herein. The method can further include evaluating platelet levels after administration of an ActRIIA variant described herein (e.g., 12 hours, 24 hours, 1, 2, 3, 4, 5, 6, or 7 days, 1, 2, 3, 4, 5, 6, 7, or 8 weeks, or 1, 2, 3, 4, 5, or 6 months or more after treatment initiation).

In some embodiments, the polypeptides described herein (e.g., a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), e.g., an effective amount of an ActRIIA variant) may be administered to increase neutrophil levels (e.g., increase neutrophil count), increase or induce the differentiation and/or maturation of progenitor cells (e.g., myeloid progenitors, myeloblasts, or myelocytes) into neutrophils, and/or induce or increase neutrophil formation or production in a subject in need thereof. In some embodiments, the subject may have or be at risk of developing a disease or condition associated with low neutrophil levels (e.g., neutropenia). The invention also includes methods of treating a subject having or at risk of developing (e.g., treating, delaying the development of, and/or preventing) neutropenia by administering to the subject an effective amount of a polypeptide described herein (e.g., a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), e.g., an effective amount of an ActRIIA variant). In any of the methods described herein, a subject having or at risk of developing low neutrophil levels (e.g., low neutrophil cell counts) has or is at risk of developing neutropenia. In some embodiments, the neutropenia is associated with a bone marrow defect, a myelodysplastic syndrome, bone marrow transplantation, myelofibrosis, aplastic anemia, Fanconi anemia, Diamond Blackfan anemia, Shwachman Diamond syndrome, paroxysmal nocturnal hemoglobinuria, cancer (e.g., leukemia), a vitamin deficiency (e.g., B-12 deficiency or folate deficiency), an enlarged spleen, an autoimmune disease (e.g., granulomatosis with polyangiitis, lupus (e.g., SLE), Evans syndrome, Felty syndrome, Crohn's disease, or rheumatoid arthritis), viral infection (e.g., chickenpox, Epstein-Barr, Hepatitis A, Hepatitis B, Hepatitis C, HIV/AIDS, cytomegalovirus, Dengue fever, or measles), a bacterial infection (e.g., tuberculosis, salmonella infection, or sepsis), cancer treatment (e.g., chemotherapy or radiation therapy), treatment with other medications (e.g., medication used to treat overactive thyroid, such as methimazole and propylthiouracil; an antibiotic, such as vancomycin, penicillin G, trimethoprim, and oxacillin; an antiviral drug, such as ganciclovir and valganciclovir; an anti-inflammatory medication for ulcerative colitis or rheumatoid arthritis, such as sulfasalazine; a drug used to treat irregular heart rhythms, such as quinidine and procainamide; an anticonvulsant, such as phenytoin and valproate; an antipsychotic, such as clozapine; or levamisole), inflammation, hematopoietic stem cell transplantation, ineffective hematopoiesis, Pearson syndrome, dyskeratosis congenita, or contraindication to transfusion (e.g., patients of advanced age, patients with allo- or auto-antibodies, pediatric patients, patients with cardiopulmonary disease, or patients who object to transfusion for religious reasons (e.g., some Jehovah's Witnesses)). The myelodysplastic syndrome may be myelodysplastic syndrome with unilineage dysplasia (MDS-SLD), myelodysplastic syndrome with multilineage dysplasia (MDS-MLD), myelodysplastic syndrome with ring sideroblasts (MDS-RS, which includes single lineage dysplasia (MDS-RS-SLD) and multilineage dysplasia (MDS-RS-MLD)), myelodysplastic syndrome associated with isolated del chromosome abnormality (MDS with isolated del(5q)), myelodysplastic syndrome with excess blasts (MDS-EB; which includes myelodysplastic syndrome with excess blasts—type 1 (MDS-EB-1) and myelodysplastic syndrome with excess blasts—type 2 (MDS-EB-2)), myelodysplastic syndrome, unclassifiable (MDS-U), or myelodysplastic syndrome/myeloproliferative neoplasm with ring sideroblasts and thrombocytosis (MDS/MPN-RS-T). The myelodysplastic syndrome may be a very low, low, or intermediate risk MDS as determined by the Revised International Prognostic Scoring System (IPSS-R). The myelodysplastic syndrome may be an RS-positive myelodysplastic syndrome (e.g., the subject with a myelodysplastic syndrome may have ring sideroblasts) or a non-RS myelodysplastic syndrome (e.g., the subject with a myelodysplastic syndrome may lack ring sideroblasts). In some embodiments, the RS-positive myelodysplastic syndrome is associated with a splicing factor mutation, such as a mutation in SF3B1. In some embodiments, the MDS is associated with a defect in terminal maturation (often observed in RS-positive MDS and in subjects having splicing factor mutations). In some embodiments, the MDS is associated with a defect in early-stage hematopoiesis (e.g., commitment or early differentiation). In some embodiments, the MDS is associated with elevated endogenous erythropoietin levels. In some embodiments, the myelodysplastic syndrome is associated with hypocellular bone marrow (e.g., a subject with MDS has hypocellular bone marrow). The subject may have a low transfusion burden or a high transfusion burden. In some embodiments, the subject has a low transfusion burden and received 1-3 RBC units in the eight weeks prior to treatment with an ActRIIA variant described herein. In some embodiments, the subject has a low transfusion burden and did not receive a transfusion (received 0 RBC units) in the eight weeks prior to treatment with an ActRIIA variant described herein. In some embodiments, the subject does not respond well to erythropoietin (EPO) or is susceptible to adverse effects of EPO (e.g., hypertension, headaches, vascular thrombosis, influenza-like syndrome, obstruction of shunts, and myocardial infarction). The compositions and methods described herein can also be used to treat subjects that do not respond to an erythroid maturation agent. In some embodiments, the subject has previously been treated with an ESA. In some embodiments, the subject has not previously been treated with an ESA. In some embodiments, the neutropenia is chronic idiopathic neutropenia. In some embodiments, the neutropenia is familial neutropenia (also referred to as inherited neutropenia, e.g., cyclic neutropenia, chronic benign neutropenia, or severe congenital neutropenia (SCN), which may be associated with mutations in the genes ELANE (associated with SCN1), HAX1 (associated with SCN3), G6PC3 (associated with SCN4), GFI1 (associated with SCN2), CSF3R, WAS (associated with X-linked neutropenia/X-linked SCN), CXCR4, VPS45A (associated with SCN5), or JAGN1). In some embodiments, the methods described herein are directed to affecting myostatin, activin A, activin B, and/or BMP9 signaling (e.g., reducing or inhibiting the binding of activin A, activin B, myostatin, and/or BMP9 to their endogenous receptors, e.g., ActRIIA, ActRIIB, and/or BMPRII) in a subject having or at risk of developing a disease or condition involving low neutrophil levels (e.g., neutropenia). In some embodiments, affecting myostatin, activin A, activin B, and/or BMP9 signaling results in an increase in the subject's neutrophil levels (e.g., an increase in neutrophil count, e.g., an increase in neutrophil production or formation) or an increase in the differentiation and/or maturation of progenitor cells (e.g., myeloid progenitors, myeloblasts, or myelocytes) into neutrophils. In some embodiments, the methods described herein increase neutrophil levels (e.g., neutrophil cell counts), increase or induce neutrophil formation or production, and/or increase or induce the differentiation and/or maturation of progenitor cells into neutrophils compared to measurements obtained prior to treatment or compared to measurements obtained from untreated subjects having the same disease or condition. In some embodiments, the methods described herein reduce the susceptibility of the subject to infection. In some embodiments, the subject is identified as having neutropenia prior to treatment with an ActRIIA variant described herein. In some embodiments, the method includes a step of identifying the subject as having neutropenia (e.g., by evaluating neutrophil levels) prior to treatment with an ActRIIA variant described herein. The method can further include evaluating neutrophil levels after administration of an ActRIIA variant described herein (e.g., 12 hours, 24 hours, 1, 2, 3, 4, 5, 6, or 7 days, 1, 2, 3, 4, 5, 6, 7, or 8 weeks, or 1, 2, 3, 4, 5, or 6 months or more after treatment initiation).

In some embodiments, the polypeptides described herein (e.g., a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), e.g., an effective amount of an ActRIIA variant) may be administered to increase the maturation and/or differentiation of erythroid progenitors (early or late- (e.g., terminal) stage progenitors, e.g., early-stage erythroid progenitors, such burst forming unit-erythroid cells (BFU-Es) and/or colony forming unit-erythroid cells (CFU-Es), e.g., increase the maturation and/or differentiation of BFU-Es and/or CFU-Es into proerythroblasts, reticulocytes, or red blood cells, e.g., increase proerythroblast and/or reticulocyte numbers), increase late-stage precursor (erythroid precursor) maturation (e.g., terminal maturation, such as the maturation of reticulocytes into red blood cells, or the maturation of erythroblasts into reticulocytes and/or red blood cells), recruit early-stage progenitors into the erythroid lineage, increase the number of early-stage erythroid precursors and/or progenitors (e.g., expand the early-stage precursor population to provide a continuous supply of precursors to replenish polychromatic erythroblasts and allow for a continuous supply of maturing reticulocytes), promote the progression of erythroid precursors and/or progenitors through erythropoiesis, and/or reduce the accumulation of red blood cell progenitor cells (e.g., by stimulating progenitor cells to progress to maturation) in a subject in need thereof. In some embodiments, the subject may have or be at risk of developing a disease or condition associated with low red blood cell levels (e.g., anemia). In some embodiments, the subject may have or be at risk of developing anemia (e.g., the subject may have or be at risk of developing anemia due to other diseases or conditions, such as a myelodysplastic syndrome or myelofibrosis, or due to a medical treatment, such as treatment with a JAK inhibitor (e.g., treatment with ruxolitinib or fedratinib for myelofibrosis)). The invention also includes methods of treating a subject having or at risk of developing (e.g., treating, delaying the development of, and/or preventing) congenital dyserythropoietic anemia or congenital sideroblastic anemia, or anemia associated with a myelodysplastic syndrome, myelofibrosis, myelofibrosis treatment, thalassemia (e.g., α- or β-thalassemia), Pearson syndrome, dyskeratosis congenita, or ineffective hematopoiesis (e.g., ineffective erythropoiesis) by administering to the subject an effective amount of a polypeptide described herein (e.g., a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), e.g., an effective amount of an ActRIIA variant). In some embodiments, the congenital sideroblastic anemia is associated with a mutation in ALAS2, SLC25A38, FECH, GLRX5, HSPA9, HSCB, SLC25A38, or ABCB7. In some embodiments, the congenital sideroblastic anemia is associated with a mutation in PUS1, YARS2, LARS2, TRNT1, MT-ATP6, NDUFB11, or SLC19A2, or with an mtDNA mutation. The myelodysplastic syndrome may be myelodysplastic syndrome with unilineage dysplasia (MDS-SLD), myelodysplastic syndrome with multilineage dysplasia (MDS-MLD), myelodysplastic syndrome with ring sideroblasts (MDS-RS, which includes single lineage dysplasia (MDS-RS-SLD) and multilineage dysplasia (MDS-RS-MLD)), myelodysplastic syndrome associated with isolated del chromosome abnormality (MDS with isolated del(5q)), myelodysplastic syndrome with excess blasts (MDS-EB; which includes myelodysplastic syndrome with excess blasts—type 1 (MDS-EB-1) and myelodysplastic syndrome with excess blasts—type 2 (MDS-EB-2)), myelodysplastic syndrome, unclassifiable (MDS-U), or myelodysplastic syndrome/myeloproliferative neoplasm with ring sideroblasts and thrombocytosis (MDS/MPN-RS-T). The myelodysplastic syndrome may be a very low, low, or intermediate risk MDS as determined by the Revised International Prognostic Scoring System (IPSS-R). The myelodysplastic syndrome may be an RS-positive myelodysplastic syndrome (e.g., the subject with a myelodysplastic syndrome may have ring sideroblasts) or a non-RS myelodysplastic syndrome (e.g., the subject with a myelodysplastic syndrome may lack ring sideroblasts). In some embodiments, the RS-positive myelodysplastic syndrome is associated with a splicing factor mutation, such as a mutation in SF3B1. In some embodiments, the MDS is associated with a defect in terminal maturation (often observed in RS-positive MDS and in subjects having splicing factor mutations, such a subject may have increased erythroid progenitor cells in the bone marrow relative to a healthy subject). In some embodiments, the MDS is associated with a defect in early-stage hematopoiesis (e.g., early-stage erythroid cell development, such as commitment or early differentiation, such a subject may have fewer erythroid progenitor cells in the bone marrow compared to a healthy subject or to a subject with a defect in terminal maturation). In some embodiments, the MDS is associated with elevated endogenous erythropoietin levels. In some embodiments, the myelodysplastic syndrome is associated with hypocellular bone marrow (e.g., a subject with MDS has hypocellular bone marrow). The subject may have a low transfusion burden or a high transfusion burden. In some embodiments, the subject has a low transfusion burden and received 1-3 RBC units in the eight weeks prior to treatment with an ActRIIA variant described herein. In some embodiments, the subject has a low transfusion burden and did not receive a transfusion (received 0 RBC units) in the eight weeks prior to treatment with an ActRIIA variant described herein. In any of the methods described herein, a subject having or at risk of developing low red blood cell levels (e.g., low hemoglobin levels, low hematocrit, or low red blood cell counts) has or is at risk of developing anemia. In some embodiments, the methods described herein are directed to affecting myostatin, activin A, activin B, and/or BMP9 signaling (e.g., reducing or inhibiting the binding of activin A, activin B, myostatin, and/or BMP9 to their endogenous receptors, e.g., ActRIIA, ActRIIB, and/or BMPRII) in a subject having or at risk of developing anemia associated with a myelodysplastic syndrome, myelofibrosis, myelofibrosis treatment, ineffective hematopoiesis (e.g., ineffective erythropoiesis), Pearson syndrome, dyskeratosis congenita, congenital dyserythropoietic anemia, or congenital sideroblastic anemia. In some embodiments, affecting myostatin, activin A, activin B, and/or BMP9 signaling results in an increase in the subject's red blood cell levels, an increase in red blood cell formation or production, an increase the maturation and/or differentiation of erythroid progenitors, an increase in late-stage erythroid precursor maturation, recruitment of early-stage progenitors into the erythroid lineage, an increase in the number of early-stage erythroid precursors and/or progenitors (e.g., an expansion of the early-stage precursor and/or progenitor population), progression of erythroid precursors and/or progenitors through erythropoiesis or a reduction the accumulation of red blood cell progenitor cells. In some embodiments, the subject does not respond well to erythropoietin (EPO) or is susceptible to adverse effects of EPO (e.g., hypertension, headaches, vascular thrombosis, influenza-like syndrome, obstruction of shunts, and myocardial infarction). The compositions and methods described herein can also be used to treat subjects that do not respond to an erythroid maturation agent. In some embodiments, the subject has previously been treated with an ESA. In some embodiments, the subject has not previously been treated with an ESA. In some embodiments, the methods described herein increase red blood cell levels (e.g., hemoglobin levels, hematocrit, red blood cell counts, red blood cell volume, or red cell mass), increase or induce red blood cell formation or production, increase the maturation and/or differentiation of erythroid progenitors, increase late-stage erythroid precursor maturation, recruit early-stage progenitors into the erythroid lineage, increase the number of early-stage erythroid precursors and/or progenitors, promote the progression of erythroid precursors and/or progenitors through erythropoiesis, and/or reduce the accumulation of red blood cell progenitor cells compared to measurements obtained prior to treatment or compared to measurements obtained from untreated subjects having the same disease or condition. In some embodiments, the compositions and methods described herein reduce the need of a subject for a blood transfusion (e.g., reduce transfusion burden, for example, the subject no longer needs blood transfusions, or the subject needs less frequent blood transfusion than before treatment with the compositions and methods described herein). In some embodiments, the compositions and methods described herein slow or inhibit the progression of lower-risk MDS to higher-risk MDS and/or acute myeloid leukemia (AML). For example, treatment of anemia in a subject having very low, low, or intermediate risk MDS and a low transfusion burden may lead to a hemoglobin increase of greater than or equal to 1.5 g/dL from baseline or pretreatment measurements (e.g., for at least one day, two days, three days, four days, five days, six days, one week, two weeks, three weeks, one month, two months, or longer during treatment). In another example, treatment of anemia in a subject having very low, low, or intermediate risk MDS and a high transfusion burden may lead to a reduction of 50% or 4 RBC units transfused compared to pretreatment (e.g., comparing an eight-week period during treatment to an eight-week period prior to treatment). In some embodiments, the subject is identified as having anemia (e.g., anemia associated with a myelodysplastic syndrome, myelofibrosis, myelofibrosis treatment, ineffective hematopoiesis, Pearson syndrome, dyskeratosis congenita, congenital dyserythropoietic anemia, or congenital sideroblastic anemia) prior to treatment with an ActRIIA variant described herein. In some embodiments, the method includes a step of identifying the subject as having anemia (e.g., by evaluating red blood cell, hemoglobin, or hematocrit levels) prior to treatment with an ActRIIA variant described herein. The method can further include evaluating red blood cell, hemoglobin, or hematocrit levels after administration of an ActRIIA variant described herein (e.g., 12 hours, 24 hours, 1, 2, 3, 4, 5, 6, or 7 days, 1, 2, 3, 4, 5, 6, 7, or 8 weeks, or 1, 2, 3, 4, 5, or 6 months or more after treatment initiation).

In some embodiments, the polypeptides described herein (e.g., a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), e.g., an effective amount of an ActRIIA variant) may be administered to increase lean mass in a subject in need thereof. In some embodiments, the subject may have or be at risk of developing a disease or condition that results in muscle weakness or atrophy (e.g., a neuromuscular disease, cachexia, disuse atrophy, treatment related muscle loss or atrophy, hypotonia, hypoxia, or muscle loss or atrophy associated with a burn injury). The invention also includes methods of treating a subject having or at risk of developing (e.g., treating, delaying the development of, and/or preventing) a neuromuscular disease (e.g., a muscular dystrophy, SMA, CMT, myasthenia gravis, or multiple sclerosis), cachexia (e.g., cancer cachexia, HIV-related cachexia, cardiac cachexia (e.g., cachexia associated with heart failure), cachexia associated with chronic kidney disease, or pulmonary cachexia (e.g., cachexia associated with COPD)), disuse atrophy, treatment related muscle loss or atrophy (e.g., muscle loss of atrophy associated with glucocorticoid treatment, FGF-21 treatment, GLP-1 treatment, bariatric surgery (e.g., gastric bypass), cancer therapy, or treatment for obesity or Type 2 diabetes), hypotonia, hypoxia, or muscle loss or atrophy associated with a burn injury by administering to the subject an effective amount of a polypeptide described herein (e.g., a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), e.g., an effective amount of an ActRIIA variant). Muscular dystrophies include Duchenne muscular dystrophy (DMD), facioscapulohumeral muscular dystrophy (FSHD), Becker muscular dystrophy (BMD), myotonic dystrophy (DM), congenital muscular dystrophy, limb-girdle muscular dystrophy (LGMD), distal muscular dystrophy (DD), oculopharyngeal muscular dystrophy (OPMD), and Emery-Dreifuss muscular dystrophy (EDMD). There are thirty three types of congenital muscular dystrophies, which include congenital muscular dystrophy type 1A (MDC1A, associated with mutations in laminin alpha 2), congenital muscular dystrophy type 1C (MDC1C, associated with mutations in FKRP), congenital muscular dystrophy type 1D (MDC1 D, associated with mutations in LARGE), congenital muscular dystrophy type 1B (MDC1B), Fukuyama congenital muscular dystrophy (FCMD, associated with mutations in fukutin), muscle-eye-brain disease (MEB, which may be associated with mutations in POMGnT1), Walker-Warburg Syndrome (WWS, associated with mutations in B3GNT1 (MDDGA type), POMT1 (MDDGA1 type), POMT2 (MDDGA2 type), ISPD (MDDGA7 type), GTDC2 (MDDGA8 type), TMEM5 (MDDGA10 type), B3GALNT2 (MDDGA11 type), or SGK196 (MDDGA12 type)), rigid spine muscular dystrophy (RSMD1, associated with a mutation in SEPN1), Ullrich congenital muscular dystrophy (UCMD, associated in mutations in COLGA1, COL6A2, or COL6A3), and muscular dystrophies associated with mutations in integrin alpha 7, integrin alpha 9, DOK7, laminin NC, SBP2, or choline kinase beta. In some embodiments, the methods described herein increase muscle mass, e.g., increase muscle mass compared to measurements obtained prior to treatment or compared to muscle mass typically observed in untreated subjects having the same disease or condition. In some embodiments, the methods described herein increase lean mass, e.g., increase lean mass compared to measurements obtained prior to treatment or compared to lean mass typically observed in untreated subjects having the same disease or condition. In some embodiments, the muscle is skeletal muscle. In some embodiments, the methods described herein are directed to affecting myostatin, activin A, activin B, and/or BMP9 signaling (e.g., reducing or inhibiting the binding of activin A, activin B, myostatin, and/or BMP9 to their endogenous receptors, e.g., ActRIIA, ActRIIB, and/or BMPRII) in a subject having or at risk of developing a neuromuscular disease, cachexia, disuse atrophy, treatment related muscle loss or atrophy, hypotonia, hypoxia, or muscle loss or atrophy associated with a burn injury. In some embodiments, affecting myostatin, activin A, activin B, and/or BMP9 signaling results in an increase in the subject's muscle mass or an increase in the subject's lean mass. In some embodiments, the subject is identified as having a disease or condition that results in muscle weakness or atrophy (e.g., a neuromuscular disease, cachexia, disuse atrophy, treatment related muscle loss or atrophy, hypotonia, hypoxia, or muscle loss or atrophy associated with a burn injury) prior to treatment with an ActRIIA variant described herein. In some embodiments, the method includes a step of identifying the subject as having a disease or condition that results in muscle weakness or atrophy (e.g., by evaluating lean mass, muscle mass, or strength or by genetic testing for congenital muscular dystrophy) prior to treatment with an ActRIIA variant described herein. The method can further include evaluating lean mass, muscle mass, or strength after administration of an ActRIIA variant described herein (e.g., 12 hours, 24 hours, 1, 2, 3, 4, 5, 6, or 7 days, 1, 2, 3, 4, 5, 6, 7, or 8 weeks, or 1, 2, 3, 4, 5, or 6 months or more after treatment initiation).

In some embodiments, the polypeptides described herein (e.g., a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), e.g., an effective amount of an ActRIIA variant) may be administered to reduce the risk or occurrence of bone fracture in a subject in need thereof. In some embodiments, the subject may have or be at risk of developing a disease or condition involving bone damage (e.g., osteogenesis imperfecta, androgen deprivation therapy-related bone loss, estrogen deprivation therapy-related bone loss, neuromuscular disease-related bone loss, burn-induced bone loss (e.g., bone loss associated with a burn injury), or anorexia-related bone loss). The invention also includes methods of treating a subject having or at risk of developing (e.g., treating, delaying the development of, and/or preventing) osteogenesis imperfecta, androgen deprivation therapy-related bone loss, estrogen deprivation therapy-related bone loss, neuromuscular disease-related bone loss, burn-induced bone loss, or anorexia-related bone loss by administering to the subject an effective amount of a polypeptide described herein (e.g., a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), e.g., an effective amount of an ActRIIA variant). In some embodiments, the methods described herein increase bone mineral density (e.g., increase bone mass), reduce bone resorption (e.g., reduce bone catabolic activity), increase bone formation (e.g., increase bone anabolic activity or increase osteogenesis), increase bone strength, reduce the risk of bone fracture or reduce the occurrence of bone fracture, increase osteoblast activity or osteoblastogenesis, and/or decrease osteoclast activity or osteoclastogenesis compared to measurements obtained prior to treatment or compared measurements from uncreated subjects having the same disease or condition. In some embodiments, the methods described herein affect myostatin, activin A, activin B, and/or BMP9 signaling (e.g., reduce or inhibit the binding of activin A, activin B, myostatin, and/or BMP9 to their endogenous receptors, e.g., ActRIIA, ActRIIB, and/or BMPRII) in a subject having or at risk of developing osteogenesis imperfecta, androgen deprivation therapy-related bone loss, estrogen deprivation therapy-related bone loss, neuromuscular disease-related bone loss, burn-induced bone loss, or anorexia-related bone loss. In some embodiments, affecting myostatin, activin A, activin B, and/or BMP9 signaling results in an increase in the subject's bone mineral density or bone formation, a decrease in the subject's bone resorption, or a decrease in the risk or occurrence of bone fracture. In some embodiments, the bone is cortical or trabecular bone. In some embodiments, the subject is identified as having a disease or condition involving bone damage (e.g., osteogenesis imperfecta, androgen deprivation therapy-related bone loss, estrogen deprivation therapy-related bone loss, neuromuscular disease-related bone loss, burn-induced bone loss (e.g., bone loss associated with a burn injury), or anorexia-related bone loss) prior to treatment with an ActRIIA variant described herein. In some embodiments, the method includes a step of identifying the subject as having a disease or condition involving bone damage prior to treatment with an ActRIIA variant described herein. The method can further include evaluating bone mineral density, bone formation, or bone resorption after administration of an ActRIIA variant described herein (e.g., 12 hours, 24 hours, 1, 2, 3, 4, 5, 6, or 7 days, 1, 2, 3, 4, 5, 6, 7, or 8 weeks, or 1, 2, 3, 4, 5, or 6 months or more after treatment initiation).

The invention also includes methods of treating a subject having or at risk of developing (e.g., treating, delaying the development of, and/or preventing) an age-related or treatment-related metabolic disease (e.g., age-related or treatment-related obesity, Type 1 diabetes, or Type 2 diabetes) by administering to the subject an effective amount of a polypeptide described herein (e.g., a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), e.g., an effective amount of an ActRIIA variant). In some embodiments, the polypeptides described herein may be administered to a subject to prevent the development of obesity (e.g., in a subject at risk of developing obesity due to advanced age or treatment with a medication associated with the development of obesity, such as a glucocorticoid (e.g., a corticosteroid, such as prednisone), a selective serotonin reuptake inhibitor (SSRI, e.g., paroxetine, mirtazapine, fluoxetine, escitalopram, sertraline, tricyclic antidepressants (e.g., amitriptyline), a mood stabilizers (e.g., valproic acid, lithium), an antipsychotic (e.g., olanzapine, chlorpromazine, clozapine), and a diabetes medication (e.g., insulin, chlorpropamide)) and/or to treat a subject already having and/or diagnosed with age-related or treatment-related metabolic disease (e.g., age-related or treatment-related obesity). In some embodiments, the polypeptides described herein may be administered to a subject to prevent the development of diabetes (e.g., Type 1 or Type 2 diabetes associated with advanced age or treatment with a medication associated with the development of diabetes, such as a glucocorticoid (e.g., a corticosteroid, e.g., glucocorticoid-induced diabetes mellitus), an SSRIs, a serotonin-norepinephrine reuptake inhibitors (SNRI), a mood stabilizer (e.g., lithium and valproic acid), and an antipsychotic (e.g., olanzapine and clozapine)) and/or to treat a subject already having and/or diagnosed with age-related or treatment-related metabolic disease (e.g., age-related or treatment-related diabetes). The method may also include the step of identifying the subject as having age-related or treatment-related metabolic disease prior to treatment with an ActRIIA variant described herein. A subject at risk of developing age-related to treatment-related metabolic disease (e.g., age-related or treatment-related diabetes) may be administered an ActRIIA variant described herein prophylactically, such that the extracellular ActRIIA variant may maintain the normal function and health of β-cells and/or prevent or delay autoimmune inflammatory damage to β-cells. In other embodiments, the polypeptides described herein (e.g., a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)), e.g., an effective amount of an ActRIIA variant) may be administered to an individual before diagnosis with age-related or treatment-related metabolic disease (e.g., age-related or treatment-related diabetes, e.g., Type 2 diabetes) or the development of clinical symptoms of diabetes, e.g., high blood glucose level, high fasting insulin level, insulin resistance, polyuria, polydipsia, and polyphagia. Administration of an ActRIIA variant described herein may reduce bodyweight by decreasing the amount of body fat. In some embodiments, the ActRIIA variant decreases the amount of body fat while maintaining or increasing the amount of lean mass. In some embodiments, an extracellular ActRIIA variant may be administered to a patient prior to the patient needing insulin. In some embodiments, the administration of extracellular ActRIIA variants may delay, reduce, or eliminate the need for insulin treatment in diabetic patients. For example, administration of the extracellular ActRIIA variants of the invention to a subject may help to increase the rate of glucose clearance from the blood. In some embodiments, the methods described herein reduce body fat (e.g., reduce the amount of subcutaneous, visceral, and/or hepatic fat, reduce adiposity, reduce the weights of epididymal and perirenal fat pads, or reduce body fat percentage). In some embodiments, the methods described herein reduce body weight or reduce body weight gain (e.g., reduce the percentage of body weight gain). In some embodiments, the methods described herein reduce the proliferation of adipose cells. In some embodiments, the methods described herein reduce LDL. In some embodiments, the methods described herein reduce triglycerides. In some embodiments, the methods described herein improve the serum lipid profile of the subject. In some embodiments, the methods described herein reduce body fat and increase muscle mass. In some embodiments, the methods described herein reduce blood glucose levels (e.g., fasting glucose levels) or and/or increase glucose clearance. In some embodiments, the methods described herein reduce fasting insulin levels and/or improve insulin sensitivity (e.g., reduce insulin resistance). In some embodiments, the methods described herein regulate insulin biosynthesis and/or secretion from β-cells. These outcomes can be assessed by comparing measurements obtained after treatment to measurements taken prior to treatment or by comparing measurements obtained after treatment to measurements from untreated control subjects having the same disease or condition. In some embodiments, the methods described herein do not affect the appetite for food intake. In some embodiments, the methods described herein affect myostatin, activin A, activin B, and/or BMP9 signaling (e.g., reduce or inhibit the binding of activin A, activin B, myostatin, and/or BMP9 to their endogenous receptors, e.g., ActRIIA, ActRIIB, and/or BMPRII) in a subject having or at risk of developing an age-related or treatment-related metabolic disease. In some embodiments, affecting myostatin, activin A, activin B, and/or BMP9 signaling results in a reduction body fat (e.g., amount of body fat or body fat percentage), a reduction in body weight or body weight gain, a reduction in fasting insulin levels, an increase in glucose clearance, an improvement in serum lipid profile, or an increase in insulin sensitivity (e.g., a reduction in insulin resistance). The method can further include evaluating body fat (e.g., amount of body fat or body fat percentage), body weight or body weight gain, fasting insulin levels, glucose clearance, serum lipid profile, or insulin sensitivity after administration of an ActRIIA variant described herein (e.g., 12 hours, 24 hours, 1, 2, 3, 4, 5, 6, or 7 days, 1, 2, 3, 4, 5, 6, 7, or 8 weeks, or 1, 2, 3, 4, 5, or 6 months or more after treatment initiation).

In some embodiments, the methods described herein (e.g., the methods of treating any of the diseases or conditions described herein) do not cause any vascular complications in the subject, such as increased vascular permeability or leakage.

In any of the methods described herein, a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-71 (e.g., SEQ ID NOs: 6-71)) that further includes a C-terminal extension of one or more amino acids (e.g., 1, 2, 3, 4, 5, 6 or more amino acids) may be used as the therapeutic protein. In any of the methods described herein, a dimer (e.g., homodimer or heterodimer) formed by the interaction of two Fc domain monomers that are each fused to a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) may be used as the therapeutic protein. In any of the methods described herein, a polypeptide including an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) fused to a moiety (e.g., an Fc domain monomer, a wild-type Fc domain, an Fc domain with amino acid substitutions (e.g., one more substitutions that reduce dimerization), an albumin-binding peptide, a fibronectin domain, or a human serum albumin) may be used as the therapeutic protein. Nucleic acids encoding the polypeptides described herein, or vectors containing said nucleic acids can also be administered according to any of the methods described herein. In any of the methods described herein, the polypeptide, nucleic acid, or vector can be administered as part of a pharmaceutical composition. Compositions that can be administered to a subject according to the methods described herein are provided in Table 4, below.

TABLE 4 Row Composition   1 A polypeptide comprising an extracellular activin receptor type IIa   (ActRIIa) variant, the variant having a sequence of GAILGRSETQECLX₁X₂NANWX₃X₄X₅X₆TNQTGVEX₇CX₈GX₉X₁₀X₁₁X₁₂X₁₃X₁₄HCX₁₅ATWX₁₆NI SGSIEIVX₁₇X₁₈GCX₁₉X₂₀X₂₁DX₂₂NCYDRTDCVEX₂₃X₂₄X₂₅X₂₆PX₂₇VYFCCCEGNMCNEKFSYF PEMEVTQPTS (SEQ ID NO: 1), wherein X₁ is F or Y; X₂ is For Y; X₃ is E or A; X₄ is K or L; X₅ is D or E;  X₆ is R or A; X₇ is P or R; X₈ is Y or E; X₉ is D or E; X₁₀ is K or Q; X₁₁  is D or A; X₁₂ is K or A; X₁₃ is R or A; X₁₄ is R or L; X₁₅ is F or Y; X₁₆ is K, R, or A; X₁₇ is K, A, Y, F, or I; X₁₈ is Q or K; X₁₉ is W or A; X₂₀ is  L or A; X₂₁ is D, K, R, A, F, G, M, N, or I; X₂₂ is I, F, or A; X₂₃ is K or T; X₂₄ is K or E; X₂₅ is D or E; X₂₆ is S or N; and X₂₇ is E or Q, and wherein the variant has at least one amino acid substitution relative to a  wild-type extracellular ActRIIa having the sequence of SEQ ID NO: 73 or an extracellular ActRIIa having any one of the sequences of SEQ ID NOs: 76-96.   2 The polypeptide of row 1, wherein the variant has a sequence of GAILGRSETQECLFX₂NANWX₃X₄X₅X₆TNQTGVEX₇CX₈GX₉KX₁₁X₁₂X₁₃X₁₄HCX₁₅ATWX₁₆NIS GSIEIVX₁₇ X₁₈GCX₁₉X₂₀X₂₁DX₂₂NCYDRTDCVEX₂₃X₂₄X₂₅X₂₆PX₂₇VYFCCCEGNMCNEKFSYFPEMEVTQP TS (SEQ ID NO: 2).   3 The polypeptide of row 1 or 2, wherein the variant has a sequence of GAILGRSETQECLFX₂NANWEX₄X₅RTNQTGVEX₇CX₈GX₉KDKRX₁₄HCX₁₅ATWX₁₆NISGSIEIV KX₁8GCWLDDX₂₂NCYDRTDCVEX₂₃X₂₄X₂₅X₂₆PX₂₇VYFCCCEGNMCNEKFSYFPEMEVTQPTS (SEQ ID NO: 3).   4 The polypeptide of any one of rows 1-3, wherein the variant has a   sequence of GAILGRSETQECLFX₂NANWEX₄DRTNQTGVEX₇CX₈GX₉KDKRX₁₄HCX₁₅ATWX₁₆NISGSIEIV KX₁₈GCWLDDX₂₂NCYDRTDCVEX₂₃KX₂₅X₂₆PX₂₇VYFCCCEGNMCNEKFSYFPEMEVTQPTS (SEQ ID NO: 4).   5 The polypeptide of any one of rows 1-4, wherein the variant has a  sequence of GAILGRSETQECLFX₂NANWEX₄DRTNQTGVEPCX₈GX₉KDKRX₁₄HCFATWKNISGSIEIVKX₁₈ GCWLDDINCYDRTDCVEX₂₃KX₂₅X₂₆PX₂₇VYFCCCEGNMCNEKFSYFPEMEVTQPTS (SEQ ID NO: 5).   6 The polypeptide of row 1, wherein X₁ is F.   7 The polypeptide of row 1, wherein X₁ is Y.   8 The polypeptide of row 1, 6, or 7 wherein X₁₀ is K.   9 The polypeptide of row 1, 6, or 7 wherein X₁₀ is Q.  10 The polypeptide of any one of rows 1-9, wherein X₂ is F.  11 The polypeptide of any one of rows 1-9, wherein X₂ is or Y.  12 The polypeptide of any one of rows 1, 2, and 6-11, wherein X₃ is E.  13 The polypeptide of any one of rows 1, 2, and 6-11, wherein X₃ is A.  14 The polypeptide of any one of rows 1-13, wherein X₄ is K.  15 The polypeptide of any one of rows 1-13, wherein X₄ is L.  16 The polypeptide of any one of rows 1, 2, 3, and 6-15, wherein X₅ is D.  17 The polypeptide of any one of rows 1, 2, 3, and 6-15, wherein X₅ is E.  18 The polypeptide of any one of rows 1, 2 and 6-17, wherein X₆ is R.  19 The polypeptide of any one of rows 1, 2 and 6-17, wherein X₆ is A.  20 The polypeptide of any one of rows 1-4 and 6-19, wherein X₇ is P.  21 The polypeptide of any one of rows 1-4 and 6-19, wherein X₇ is R.  22 The polypeptide of any one of rows 1-21, wherein X₈ is Y.  23 The polypeptide of any one of rows 1-21, wherein X₈ is E.  24 The polypeptide of any one of rows 1-23, wherein X₉ is D.  25 The polypeptide of any one of rows 1-23, wherein X₉ is E.  26 The polypeptide of any one of rows 1, 2 and 6-25, wherein X₁₁ is D.  27 The polypeptide of any one of rows 1, 2 and 6-25, wherein X₁₁ is A.  28 The polypeptide of any one of rows 1, 2 and 6-27, wherein X₁₂ is K.  29 The polypeptide of any one of rows 1, 2 and 6-27, wherein X₁₂ is A.  30 The polypeptide of any one of rows 1, 2 and 6-29, wherein X₁₃ is R.  31 The polypeptide of any one of rows 1, 2 and 6-29, wherein X₁₃ is A.  32 The polypeptide of any one of rows 1-31, wherein X₁₄ is R.  33 The polypeptide of any one of rows 1-31, wherein X₁₄ is L.  34 The polypeptide of any one of rows 1-4 and 6-33, wherein X₁₅ is F.  35 The polypeptide of any one of rows 1-4 and 6-33, wherein X₁₅ is Y.  36 The polypeptide of any one of rows 1-4 and 6-35, wherein X₁₆ is K.  37 The polypeptide of any one of rows 1-4 and 6-35, wherein X₁₆ is R.  38 The polypeptide of any one of rows 1-4 and 6-35, wherein X₁₆ is A.  39 The polypeptide of any one of rows 1, 2 and 6-38, wherein X₁₇ is K.  40 The polypeptide of any one of rows 1, 2 and 6-38, wherein X₁₇ is A.  41 The polypeptide of any one of rows 1, 2 and 6-38, wherein X₁₇ is Y.  42 The polypeptide of any one of rows 1, 2 and 6-38, wherein X₁₇ is F.  43 The polypeptide of any one of rows 1, 2 and 6-38, wherein X₁₇ is I.  44 The polypeptide of any one of rows 1-43, wherein X₁₈ is Q.  45 The polypeptide of any one of rows 1-43, wherein X₁₈ is K.  46 The polypeptide of any one of rows 1, 2 and 6-45, wherein X₁₉ is W.  47 The polypeptide of any one of rows 1, 2 and 6-45, wherein X₁₉ is A.  48 The polypeptide of any one of rows 1, 2 and 6-47, wherein X₂₀ is L.  49 The polypeptide of any one of rows 1, 2 and 6-47, wherein X₂₀ is A.  50 The polypeptide of any one of rows 1, 2 and 6-49, wherein X₂₁ is D.  51 The polypeptide of any one of rows 1, 2 and 6-49, wherein X₂₁ is K.  52 The polypeptide of any one of rows 1, 2 and 6-49, wherein X₂₁ is R.  53 The polypeptide of any one of rows 1, 2 and 6-49, wherein X₂₁ is A.  54 The polypeptide of any one of rows 1, 2 and 6-49, wherein X₂₁ is F.  55 The polypeptide of any one of rows 1, 2 and 6-49, wherein X₂₁ is G.  56 The polypeptide of any one of rows 1, 2 and 6-49, wherein X₂₁ is M.  57 The polypeptide of any one of rows 1, 2 and 6-49, wherein X₂₁ is N.  58 The polypeptide of any one of rows 1, 2 and 6-49, wherein X₂₁ is I.  59 The polypeptide of any one of rows 1-4 and 6-58, wherein X₂₂ is I.  60 The polypeptide of any one of rows 1-4 and 6-58, wherein X₂₂ is F.  61 The polypeptide of any one of rows 1-4 and 6-58, wherein X₂₂ is A.  62 The polypeptide of any one of rows 1-61, wherein X₂₃ is K.  63 The polypeptide of any one of rows 1-61, wherein X₂₃ is T.  64 The polypeptide of any one of rows 1, 2, 3, and 6-63, wherein X₂₄ is K.  65 The polypeptide of any one of rows 1, 2, 3, and 6-63, wherein X₂₄ is E.  66 The polypeptide of any one of rows 1-65, wherein X₂₅ is D.  67 The polypeptide of any one of rows 1-65, wherein X₂₅ is E.  68 The polypeptide of any one of rows 1-67, wherein X₂₆ is S.  69 The polypeptide of any one of rows 1-67, wherein X₂₆ is N.  70 The polypeptide of any one of rows 1-69, wherein X₂₇ is E.  71 The polypeptide of any one of rows 1-69, wherein X₂₇ is Q.  72 The polypeptide of any one of rows 1-71, wherein X₂₃ is T, X₂₄ is E,   X₂₅ is E, and X₂₆ is N.  73 The polypeptide of any one of rows 1-71, wherein X₂₃ is T, X₂₄ is K,  X₂₅ is E, and X₂₆ is N.  74 The polypeptide of any one of rows 1-73, wherein X₁₇ is K.  75 The polypeptide of row 1, wherein the variant has the sequence of  any one of SEQ ID NOs: 6-72.  76 The polypeptide of row 75, wherein the variant has the sequence of  SEQ ID NO: 69.  77 The polypeptide of row 75, wherein the variant has the sequence of  SEQ ID NO: 58.  78 The polypeptide of row 75, wherein the variant has the sequence of  SEQ ID NO: 6.  79 The polypeptide of row 75, wherein the variant has the sequence of  SEQ ID NO: 38.  80 The polypeptide of row 75, wherein the variant has the sequence of  SEQ ID NO: 41.  81 The polypeptide of row 75, wherein the variant has the sequence of  SEQ ID NO: 44.  82 The polypeptide of row 75, wherein the variant has the sequence of  SEQ ID NO: 70.  83 The polypeptide of row 75, wherein the variant has the sequence of  SEQ ID NO: 71.  84 The polypeptide of row 75, wherein the variant has the sequence of  SEQ ID NO: 72.  85 The polypeptide of any one of rows 1-84, wherein the amino acid at  position X₂₄ is replaced with the amino acid K.  86 The polypeptide of any one of rows 1-85, wherein the amino acid at  position X₂₄ is replaced with the amino acid E.  87 The polypeptide of any one of rows 1-86, further comprising a  C-terminal extension of one or more amino acids.  88 The polypeptide of row 87, wherein the C-terminal extension is NP.  89 The polypeptide of row 87, wherein the C-terminal extension is  NPVTPK (SEQ ID NO: 154).  90 The polypeptide of any one of rows 1-89, further comprising an Fc  domain monomer fused to the C-terminus of the polypeptide by way  of a linker.  91 The polypeptide of row 90, wherein the Fc domain monomer comprises  the sequence of SEQ ID NO: 97.  92 The polypeptide of any one of rows 1-89, further comprising a  wild-type Fc domain fused to the C-terminus of the polypeptide by way of a linker.  93 The polypeptide of row 92, wherein the wild-type Fc domain comprises  the sequence of SEQ ID NO: 150 or SEQ ID NO: 155.  94 The polypeptide of row 93, wherein the wild-type Fc domain comprises  the sequence of SEQ ID NO: 155.  95 The polypeptide of any one of rows 1-89, further comprising an Fc  domain comprising amino acid substitutions fused to the C-terminus of the polypeptide by way of a linker.  96 The polypeptide of row 95, wherein the Fc domain does not form a  dimer.  97 The polypeptide of any one of rows 1-89, further comprising an  albumin-binding peptide fused to the C-terminus of the polypeptide by way of a linker.  98 The polypeptide of row 97, wherein the albumin-binding peptide  comprises the sequence of SEQ ID NO: 151.  99 The polypeptide of any one of rows 1-89, further comprising a  fibronectin domain fused to the C-terminus of the polypeptide by way of a linker. 100 The polypeptide of row 99, wherein the fibronectin domain comprises  the sequence of SEQ ID NO: 152. 101 The polypeptide of any one of rows 1-89, further comprising a human  serum albumin fused to the C-terminus of the polypeptide by way of a linker. 102 The polypeptide of row 101, wherein the human serum albumin  comprises the sequence of SEQ ID NO: 153. 103 The polypeptide of row 90 or 91, wherein the polypeptide forms a  dimer. 104 The polypeptide of any one of rows 90-103, wherein the linker is  an amino acid spacer. 105 The polypeptide of row 104, wherein the amino acid spacer is GGG,  GGGA (SEQ ID NO: 98), GGGG (SEQ ID NO: 100), GGGAG (SEQ ID NO: 130), GGGAGG (SEQ ID NO: 131), or GGGAGGG (SEQ ID NO: 132). 106 The polypeptide of row 105, wherein the amino acid spacer is GGG. 107 The polypeptide of row 94 or 106, wherein the polypeptide has the  sequence of SEQ ID NO: 156. 108 The polypeptide of row 104, wherein the amino acid spacer is GGGS  (SEQ ID NO: 99), GGGGA (SEQ ID NO: 101), GGGGS (SEQ ID NO: 102), GGGGG (SEQ ID NO: 103), GGAG (SEQ ID NO: 104), GGSG (SEQ ID NO:  105), AGGG (SEQ ID NO: 106), SGGG (SEQ ID NO: 107), GAGA (SEQ ID  NO: 108), GSGS (SEQ ID NO: 109), GAGAGA (SEQ ID NO: 110), GSGSGS (SEQ ID NO: 111), GAGAGAGA (SEQ ID NO: 112), GSGSGSGS (SEQ ID NO: 113), GAGAGAGAGA (SEQ ID NO: 114), GSGSGSGSGS (SEQ ID NO: 115), GAGAGAGAGAGA (SEQ ID NO: 116), and GSGSGSGSGSGS (SEQ ID NO: 117),  GGAGGA (SEQ ID NO: 118), GGSGGS (SEQ ID NO: 119), GGAGGAGGA (SEQ  ID NO: 120), GGSGGSGGS (SEQ ID NO: 121), GGAGGAGGAGGA (SEQ ID NO:  122), GGSGGSGGSGGS (SEQ ID NO: 123), GGAGGGAG (SEQ ID NO: 124),  GGSGGGSG (SEQ ID NO: 125), GGAGGGAGGGAG (SEQ ID NO: 126), and GGSGGGSGGGSG (SEQ ID NO: 127), GGGGAGGGGAGGGGA (SEQ ID NO: 128), GGGGSGGGGSGGGGS (SEQ ID NO: 129), AAAL (SEQ ID NO: 133), AAAK (SEQ ID NO: 134), AAAR (SEQ ID NO: 135), EGKSSGSGSESKST (SEQ ID  NO: 136), GSAGSAAGSGEF (SEQ ID NO: 137), AEAAAKEAAAKA (SEQ ID NO: 138), KESGSVSSEQLAQFRSLD (SEQ ID NO: 139), GENLYFQSGG (SEQ ID NO: 140), SACYCELS (SEQ ID NO: 141), RSIAT (SEQ ID NO: 142), RPACKIPNDLKQKVMNH (SEQ ID NO: 143), GGSAGGSGSGSSGGSSGASGTGTAGGTGSGSGTGSG (SEQ ID NO: 144), AAANSSIDLISVPVDSR (SEQ ID NO: 145), GGSGGGSEGGGSEGGGSEGGGSEGGGSEGGGSGGGS (SEQ ID NO: 146),  EAAAK (SEQ ID NO: 147), or PAPAP(SEQ ID NO: 148). 109 The polypeptide of any one of rows 1-108, wherein the  polypeptide has a serum half-life of at least 7 days. 110 The polypeptide of any one of rows 1-109, wherein the polypeptide  binds to activin A, activin B, and/or myostatin and has reduced or weak binding to human BMP9. 111 The polypeptide of row 110, wherein the polypeptide does not  substantially bind to human BMP9. 112 The polypeptide of any one of rows 1-111, wherein the polypeptide  binds to human activin A with a K_(D) of 800 pM or less. 113 The polypeptide of any one of rows 1-112, wherein the polypeptide  binds to human activin B with a K_(D) of 800 pM or less. 114 The polypeptide of any one of rows 1-113, wherein the polypeptide  binds to human GDF-11 with a K_(D) of 5 pM or higher. 115 A nucleic acid molecule encoding a polypeptide of any one of  rows 1-114. 116 A vector comprising the nucleic acid molecule of row 115. 117 A host cell that expresses a polypeptide of any one of rows 1-114,  wherein the host cell comprises a nucleic acid molecule of row  115 or a vector of row 116, wherein the nucleic acid molecule or vector is expressed in the host cell. 118 A pharmaceutical composition comprising a polypeptide of any one  of rows 1-114, a nucleic acid molecule of row 115, or a vector of row 116, and one or more pharmaceutically acceptable carriers or excipients. 119 The pharmaceutical composition of row 118, wherein the polypeptide  is in a therapeutically effective amount.

EXAMPLES Example 1—Evaluation of ActRIIA Variants Binding Affinity by Surface Plasmon Resonance (SPR)

The Biacore 3000 was used to measure the kinetics of the interactions between the ActRIIA variants and the ligands Activin A, Activin B, growth differentiation factor 11 (GDF11), and BMP-9. ActRIIA variants were made by transient expression in HEK293 cell and purified from the conditioned media using Protein-A Sepharose chromatography. The ActRIIA variants were immobilized on the chip (CM4 or CM5) with capture antibodies (anti-mouse from GEGE) in flow cells 2-4 to ensure proper orientation. Flow cell 1 was used as a reference cell to subtract any nonspecific binding and bulk effects. HBS-EP+ buffer from GE Healthcare™ was used as a running buffer. Each ligand was run in a concentration series at 40 μI/min to avoid mass transport effects. The data was analyzed using Scrubber2 by BioLogic™ Software to calculate the K_(D) of each interaction (Table 5).

TABLE 5 Comparison of ActRIIA variant binding affinity (K_(D)) to various ligands Activin Activin GDF-11 BMP-9 A (K_(D)) B (K_(D)) (K_(D)) (K_(D)) Vehicle N/A N/A N/A N/A ActRIIA   1 nM 373 pM  81 pM  25 nM (SEQ ID NO: 73) ActRIIB  63 pM  23 pM 115 pM 278 pM (SEQ ID NO: 74) ActRIIA/b variant 542 pM 103 pM 186 pM   4 nM (SEQ ID NO: 69) ActRIIA/bΔ9 variant 213 pM 12.3 pM  115 pM  10 nM (SEQ ID NO: 58) ActRIIA/bΔ9 min 310 pM  88 pM 114 pM  17 nM variant (SEQ ID NO: 6) ActRIIA/b+ variant 242 pM 282 pM No  26 nM (SEQ ID NO: 149) dissociation ActRIIA/bΔ9m2 170 pM 104 pM 222 pM 13-18 nM variant (SEQ ID NO: 38) ActRIIA/bΔ9m3  71 pM 72.5 pM  117 pM  1.2 nM variant (SEQ ID NO: 41) ActRIIA/bΔ9m4 375 pM 254 pM 394 pM 14-20 nM variant (SEQ ID NO: 44) ActRIIA/bmax1 variant 232 pM  97 pM 236 pM  5.6 nM (SEQ ID NO: 70) ActRIIA/bmax2 variant 135 pM  39 pM 113 pM   5 nM (SEQ ID NO: 71) ActRIIA/bmax3 variant  89 pM  43 pM 214 pM  3.3 nM (SEQ ID NO: 72)

Example 2—Effect of ActRIIA/B-Fc on the Maturation of Erythroid Progenitors

Seven-week-old C57BL/6 mice received twice weekly dosing of either vehicle (tris-buffered saline) or 10 mg/kg ActRIIA/B-mFc (SEQ ID NO: 69 linked to a mouse Fc domain using an amino acid spacer) by intraperitoneal (IP) injection. Hematological changes in peripheral blood were assessed 12 hours, 96 hours, and 14 days after dosing.

Flow cytometry analysis and colony forming unit-erythroid (CFU-E) and burst forming unit-erythroid (BFU-E) assays were performed on bone marrow isolated cells to identify changes in erythrocyte precursors. Bone marrow cells were isolated from femurs and tibias by flushing out the bone marrow with 2% FBS in PBS, followed by straining through a 70 mm strainer.

Assessment of BFU-Es and CFU-Es

Following lysis of red blood cells, freshly isolated bone marrow cells were suspended in IMEM media to a concentration of 1×10⁷ cells/mL and plated in semi-solid methylcellulose media to a final concentration of 1×10⁵ cells/mL. For CFU-E assessment, cells were cultured in MethoCult M3334 media (Stem Cell Technologies) to support CFU-E formation. Colonies were counted after 48 hours; clusters of more than 8 cells were considered to be a CFU-E. For BFU-E assessment, cells were cultured in MethoCult SF M3436 media (Stem Cell Technologies) to support BFU-E formation. Colonies were counted after 12 days; BFU-Es were large brown colonies with cells clustered in the middle. Both CFU-Es and BFU-Es were reduced in the ActRIIA/B-mFc-treated mice 96 hours after dosing as compared to the vehicle-treated mice (FIGS. 2A-2B).

Profiling of Erythroid Precursors by Flow Cytometry

Red blood cells were lysed from freshly isolated bone marrow, and nonspecific binding was blocked by incubating the remaining cells with Fc-blocker for 30 minutes on ice. Cells were then stained with antibodies against Ter119 and CD71, and dead cells were excluded by DAPI staining. FMO controls were used for gating. An LSRII cytometer (BD) was used to analyze the samples, and data were analyzed using FlowJo software. Proerythroblasts (ProE) were cells exhibiting high CD71 and low Ter119 expression. Other progenitor populations were identified from Ter119+ cells based on size and CD71 expression: EryA representing basophilic erythroblasts (BasoE) were large cells expressing CD71; EryB representing polychromatic erythroblasts (PolyE) and orthochromatic erythroblasts (OrthoE) were small cells with high CD71 expression; and EryC representing reticulocytes were small cells with low CD71 expression. The population of ProE cells was increased in the ActRIIA/B-mFc-treated group 96 hours after dosing as compared to the vehicle-treated group (FIG. 2C).

These data indicate that ActRIIA/B-mFc increases the number of early-stage erythroid progenitor cells leaving quiescence and continuing through the erythropoiesis pathway, suggesting that ActRIIA/B-mFc has an effect on early stages of erythroid maturation by promoting the differentiation of early-stage progenitors, which may lead to RBC maturation.

In addition, increases in red blood cell numbers, hematocrit, and hemoglobin were observed starting 12 hours after treatment that persisted at the 14-day time point. Neutrophils were also increased at the 14-day time point in mice dosed twice weekly (FIGS. 3A-3D).

Example 3—Effect of ActRIIA/B-Fc on Red Blood Cells and White Blood Cells

Aging is associated with multiple cytopenias, including reductions in the volume of red blood cells and white blood cells. To assess the effects of ActRIIA/B-mFc on age-related cytopenias, 11-week old (young) and 2-year old (aged) female C57BL/6 mice were dosed twice weekly with either vehicle (TBS) or ActRIIA/B-mFc at a concentration of 10 mg/kg by intraperitoneal injection. After 6.5 weeks of dosing, venous collection was performed, and blood was collected in EDTA-containing tubes, and RBC, hemoglobin (HGB), hematocrit (HCT), and neutrophil (NEU) count were assessed. Blood was analyzed using a Heska HT5 veterinary blood analyzer. Data are shown as mean±SEM and analyzed using a 1-way ANOVA with a Dunnett's post-test. Compared to young mice, aged mice receiving vehicle had significantly reduced RBC, HGB, and HCT. However, compared with aged mice receiving vehicle, aged mice that received ActRIIA/B-mFc exhibited robust improvements in RBC, NEU, HCT, and HGB (FIGS. 4A-4D). Moreover, aged mice receiving ActRIIA/B-mFc did not differ from young mice in measurements of RBC, HGB, and HCT, and exhibited significantly greater NEU, indicating reversal of age-associated hematological deficits. These data indicate that ActRIIA/B-mFc rescues blood parameters of aged mice to those of younger mice and, accordingly, that ActRIIA/B-Fc could be a therapeutic intervention for anemia and other cytopenias, such as those observed in elderly populations.

Example 4—Effect of ActRIIA/B-Fc on Red Blood Cell Numbers in Mice Treated with an Erythropoietin Neutralizing Antibody

Mice were treated with a neutralizing monoclonal antibody (mAb) against erythropoietin (EPO) (R&D systems, cat #MAB959) with and without ActRIIA/B-mFc. Ten-week-old mice were dosed with either vehicle (TBS), ActRIIA/B-mFc (10 mg/kg at day 0), the neutralizing EPO antibody (EPO mAb, 5.5 mg/kg at days 0 and 2), or a combination of ActRIIA/B-mFc and EPO mAb. Mice were sacrificed three days after treatment (n=8) and blood was collected from cheek bleeds. Statistical analysis was performed by one-way ANOVA, Tukey multiple comparison analysis. Three days after treatment, RBC, Hgb, and Hct levels were elevated in ActRIIA/B-mFc-treated mice compared to vehicle, while treatment with EPO mAb resulted in a reduction in the same parameters compared to vehicle. Treatment with ActRIIA/B-mFc and EPO mAb in combination prevented the reduction in hematological parameters due to EPO inhibition, returning the parameters to vehicle-treated levels (FIGS. 5A-5C). These data suggest that ActRIIA/B-mFc and EPO have separate mechanisms of action, potentially acting on different stages of RBC maturation.

Example 5—Effect of ActRIIA/B-Fc on Reticulocytes in Cynomolgus Monkeys

Male and female 2-4-year-old cynomolgus monkeys were dosed subcutaneously once every other week with either vehicle or ActRIIA/B-hFc (SEQ ID NO: 69 linked to a human Fc domain (SEQ ID NO: 155) using an amino acid spacer) at doses of 3, 10 or 50 mg/kg (n=6/group) for three months. Each animal had baseline and end-of-study blood collections, which were analyzed for absolute reticulocyte number. ActRIIA/B-hFc robustly increased reticulocytes in cynomolgus monkeys (FIG. 6 ). Reticulocytes increased at the 50 mg/kg dose in both females (44.8% compared to a reduction in vehicle (−35.9%); p=0.03; FIG. 6 , left), and males (168.9% compared to a reduction in vehicle (−21.3%); p=0.003] at the 50 mg/kg dose; FIG. 6 right), *p<0.05; **p<0.01.

Example 6—Effect of ActRIIA/B-Fc on Red Blood Cell Parameters, Platelets, and Bone Growth in Human Subjects

A two-part study was performed in healthy postmenopausal women. In Part 1, subjects were randomized into four single ascending dose (SAD) groups to receive a single subcutaneous (SC) dose of ActRIIA/B-hFc (at a dose of 0.05, 0.5, 1.5, or 4.5 mg/kg) or placebo; in Part 2, subjects received either 0.75 mg/kg ActRIIA/B-hFc or placebo, randomized on a four-to-one basis, administered SC on two occasions 28 days apart. Part 1 enrolled 38 subjects, 30 received a single dose of ActRIIA/B-hFc (0.05, 0.5, 1.5, 4.5 mg/kg) and eight received placebo. Part 2 enrolled 10 subjects, eight received two doses of ActRIIA/B-hFc at 0.75 mg/kg. ActRIIA/B-hFc was well tolerated at dose levels up to 4.5 mg/kg as a single dose, and 0.75 mg/kg in multiple doses. There was a serious adverse event of lobar pneumonia due to influenza A infection in a subject on placebo. There were no discontinuations due to adverse events. The adverse events in the ActRIIA/B-hFc treated subjects were all mild or moderate in severity. The most common adverse events reported in the ActRIIA/B-hFc treated subjects were increased hemoglobin, hypertension, nausea, gastroenteritis, and injection site erythema. Subjects were evaluated to assess pharmacokinetic properties, hematological parameters, and biomarkers for target engagement and bone growth.

Mean ActRIIA/B-hFc AUC and C_(max) increased proportionally after first dose and mean biz was approximately 12 days. Mean changes from baseline in hemoglobin were observed beginning on Day 2, peaked on Day 29, and persisted through Day 42 following treatment with a single dose; mean change from baseline in hemoglobin on Day 29 in the 4.5 mg/kg group was 2.1 g/dL (FIG. 7B). Increases in hemoglobin beyond day 15 may be indicative of an effect on early precursors. The proportion of subjects with a hemoglobin increase of ≥1.5 g/dL were 12.5%, 12.5%, 50%, and 66.7% with ascending doses of ActRIIA/B-hFc, and 0% in the placebo group (FIG. 8 ). Changes from baseline in reticulocytes and red blood cell counts were also observed (FIGS. 7A and 7C), with changes in RBCs durable up to 84 days for a single dose. Increases in reticulocytes were observed as early as Day 2 and reached a peak around Day 15. The rapid increase in reticulocytes is potentially indicative of an effect on terminal differentiation. Clinically relevant increases in platelet counts were also observed beginning on Day 4 and peaked on Day 7 with a mean change from baseline of 39.2×10⁹ cells/in the 4.5 mg/kg group, sustained through Day 29 (FIG. 9 ). These data demonstrate that treatment with ActRIIA/B-hFc elicited rapid, robust, and sustained dose-dependent increases in hemoglobin, reticulocytes, and red blood cells in healthy subjects in addition to clinically meaningful increases in platelets. In addition, linear plots of mean serum ActRIIA/B-hFc concentrations showed dose-proportional serum ActRIIA/B-hFc concentrations over time for the four dose levels (FIG. 10 ).

Follicle stimulating hormone (FSH) was evaluated as a biomarker for target engagement since FSH is regulated by activins. Serum FSH was evaluated according to the instructions for the U-plex Human FSH Assay (Mesoscale Discovery). The extent of the decrease in serum FSH indicates the extent of activin inhibition (FIG. 11 ). Serum bone-specific alkaline phosphatase (BSAP) was also evaluated as a biomarker of bone growth. BSAP was evaluated according to the instructions of the Ostase® BAP EIA Immunoenzymetric Assay kit. At higher doses, ActRIIA/B-hFc led to an increase in BSAP (FIG. 12 ), indicating the potential of ActRIIA/B-hFc to increase bone mass.

Example 7—Effect of ActRIIA/B-Fc on Erythropoietin and Erythropoietin Receptor Levels Assessment of Serum Erythropoietin Levels

Eleven-week-old male mice (received from Taconic Biosciences) were treated with a single dose of 10 mg/kg ActRIIA/B-mFc by intraperitoneal (IP) injection or with vehicle. Mice were sacrificed on days 2, 4, 7, 14, 37, and 51 after treatment. Blood was sampled into EDTA tubes from a submandibular/cheek bleed and stored at 4° C. until analysis at IDEXX BioAnalytics for RBC counts. At necropsy, whole blood was drawn by cardiac bleed and collected into Microvette tubes (Sarstedt). The tubes were incubated at room temperature for two hours followed by centrifugation at 6000 RPM for 10 minutes. Serum was collected and stored at −80° C. until the analysis.

Erythropoietin (EPO) levels were measured using a mouse erythropoietin immunoassay (Quantikine ELISA kit) according to manufacturer instructions. Colorimetric readings of the ELISA plate were measured using a SpectraMax M5 microplate reader at 450 nm and background was subtracted from a reading at 540 nm. Erythropoietin concentration was transformed by creating a 4-parameter logistic curve using GraphPad Prism software. As shown in FIG. 13 , EPO levels were increased in response to ActRIIA/B-mFc treatment, even in the context of increased RBCs. Elevated serum EPO may further enhance the effect of ActRIIA/B-mFc to boost early progenitor differentiation *p<0.05, **p<0.01, ****p<0.0001 between ActRIIA/B-mFc-treated and vehicle at each time point with 2-way ANOVA followed by a Sidak post-test. Data are shown as the mean±SEM. FIG. 14 shows that EPO levels were elevated in mice treated with ActRIIA/B-mFc by day 4 through day 37 compared to vehicle-treated mice. *p≤0.05; **p≤0.01; p****≤0.0001 between ActRIIA/B-mFc-treated and vehicle-treated at each time point by t-test. Data are shown as the mean±SEM.

Assessment of Erythropoietin Receptor Expression

Eleven-week-old male mice (received from Taconic Biosciences) were treated with a single dose of 10 mg/kg ActRIIA/B-mFc by IP injection or with vehicle. Mice were sacrificed on days 4, 7 and 14 after treatment. Bone marrow cells were isolated by flushing the bone marrow from a femur. Red blood cells were removed via lysis using an ammonium chloride solution (Stem Cell Technologies). One million cells were lysed with Trizol reagent and RNA isolated using the Direct-zol RNA MicroPrep (Zymo Research) kit. cDNA was synthesized using Reverse Transcription Kit (Qiagen) and the EpoR expression measured by qPCR using the ViiA 7 real-time PCR system (Applied Biosystems). Primers used: EpoR Forward: TTCAGCGGATTCTGGAGTGCCT (SEQ ID NO: 157) and EpoR Reverse: AGCAACAGCGAGATGAGGACCA (SEQ ID NO: 158). β-actin was used as a housekeeping gene. Primers used: β-actin Forward: CATCGTGGGCCGCCCTA (SEQ ID NO: 159) and β-actin Reverse: CACCCACATAGGAGTCCTTCTG (SEQ ID NO: 160). Relative gene expression was determined using the ΔΔCT method and graphs were plotted in Graph Pad Prism. Error bars represent SEM. Statistical analysis was done using Student's t-test. As shown in FIG. 15 , EPO receptor expression was increased after ActRIIA/B-mFc treatment.

Example 8—Effect of ActRIIA/B-Fc on Red Blood Cell Parameters 12 Hours to 51 Days after a Single Administration

Seven to 16-week-old C57Bl/6 mice (received from Taconic Biosciences) were treated with a single dose of 10 mg/kg ActRIIA/B-mFc by intraperitoneal (IP) injection or with vehicle. In a first experiment, mice were sacrificed at 12 hours post-dose (7-week-old), day 7 post-dose (11-week-old), and day 14 post-dose (13-16-week-old). In further experiments, 11- to-13-week-old mice were treated with a single dose of 10 mg/kg ActRIIA/B-mFc or vehicle by IP injection and sacrificed at 12 hours post-dose, 24 hours post-dose, and on days 2, 4, 7, 14, 37, and 51 post-dose. Peripheral blood was collected in EDTA tubes via cheek bleed and stored at 4° C. until analysis at IDEXX BioAnalytics for hematologic parameters.

Mice treated with a single dose of ActRIIA/B-mFc at 10 mg/kg in the first experiment had increased red blood cells, hemoglobin, and reticulocytes just 12 hours after administration compared to vehicle-treated mice (FIG. 16A). This effect was further increased on Day 7 (FIG. 16B) and sustained through Day 14 post-dose (FIG. 16C), indicating that ActRIIA/B-mFc induced a rapid and sustained increase in red blood cell parameters. D7 and D14 N=6; 12H N=10. *p<0.05, **p<0.01, ***p<0.001 by Student's t-test. NS=not significant. Error bars are ±SEM. In further experiments, the increases in red blood cells (FIG. 17A) and hemoglobin (FIG. 17B) were observed by 12 hours after administration through at least day 51 in ActRIIA/B-mFc-treated mice compared to vehicle-treated mice, indicating that a single dose of ActRIIA/B-mFc resulted in a long-lasting effect on erythropoiesis. 12-24HR N=19; Days 37 and 51 N=10. *p≤0.05; **p≤0.01; p****≤0.0001 compared to vehicle at each time point by t-test. Data are shown as the mean±SEM.

Example 9— Effect of ActRIIA/B-Fc on Late-Stage Erythrocyte Precursors and Reticulocytes

Eleven-week-old C57Bl/6 mice (received from Taconic Biosciences) were treated with 10 mg/kg ActRIIA/B-mFc or with vehicle by intraperitoneal (IP) injection. Mice were sacrificed on day 2 or day 7 after treatment. Peripheral blood was collected by cheek bleed and stored at 4° C. until analysis at IDEXX BioAnalytics for immature reticulocyte fraction. Bone marrow cells were isolated by flushing the bone marrow from a femur, and red blood cells were removed via lysis using an ammonium chloride solution (Stem Cell Technologies). At day 7 after treatment, bone marrow cells were stained with TER119 (PE) and CD71 (FITC) antibodies, and live cells were gated as DAPI negative cells. The EryC population was defined as Ter119+; CD71−; small cells (FIG. 18A). At day 2 after treatment, enucleated reticulocytes in the bone marrow were identified using the DNA dye DRAQ5 and TER119 (PE). DRAQ5+ cells (nucleated cells) were measured as % of Ter119+ cells (erythroid cells) (FIG. 18B). At day 2 after treatment, peripheral blood was collected by cheek bleed and stored at 4° C. until measurement of immature reticulocytes in the blood was performed by staining with nucleic dye thiazole orange (IDEXX BioAnalytics) (FIG. 18C). As shown in FIGS. 18A-18C, ActRIIA/B-mFc increased the EryC population, suggesting the maturation of the EryB population to EryC, and decreased the number of nucleated cells in bone marrow and increased the percentage of immature reticulocytes in circulation, indicating that ActRIIA/B-mFc accelerated the maturation of late-stage erythrocyte precursors and the outflux of reticulocytes to circulation. N=6. *p<0.05, **p<0.01 by Student's t-test. Error bars are ±SEM.

Example 10—Effect of ActRIIA/B-Fc on Early-Stage Precursors and Erythropoiesis

Eleven-week-old C57Bl/6 mice (received from Taconic Biosciences) were treated with a single administration of vehicle or 10 mg/kg ActRIIA/B-mFc by intraperitoneal injection. Mice were sacrificed on day 2, 4 or 7 after treatment. Bone marrow cells were isolated by flushing the bone marrow from a femur, and red blood cells were removed via lysis using an ammonium chloride solution (Stem Cell Technologies). To determine CFU-E and BFU-E colony counts, bone marrow cells were cultured in semi-solid media (MethoCult M3334 for CFU-Es or MethoCult SF M3436 for BFU-Es). Numbers of colonies were counted at 24-48 hours post seeding for CFU-Es and 7 days post seeding for BFU-Es. To determine populations of erythroid precursor cells, flow cytometry was performed. Bone marrow cells were stained with DAPI and antibodies against Ter119 (PE-conjugated) and CD71 (FITC-conjugated). Live cells were gated as DAPI negative cells. The different erythroid populations were defined as follows: ProE: Ter119dim, CD71+; EryA: Ter119+, CD71+, large cells; EryB: Ter119+, CD71+, small cells. ActRIIA/B-mFc treatment increased the number of CFU-E colonies at day 2 post-dose (FIG. 19A) and decreased the EryB cell pool at day 4 (FIG. 19B). EryB cells were then repleted by day 7 (FIG. 19B). No change was observed in EryA cells (data not shown). These data support the ability of ActRIIA/B-mFc to increase early-stage precursors and progress erythroid progenitors through erythropoiesis. N=4-7, *p<0.05.

Example 11—Effect of ActRIIA/B-Fc on Early-Stage Precursors and Erythropoiesis

Eleven-week-old C57Bl/6 mice (received from Taconic Biosciences) were treated with vehicle or 10 mg/kg ActRIIA/B-mFc by intraperitoneal injection. Mice were sacrificed on day 14 after treatment. Bone marrow cells were isolated by flushing the bone marrow from a femur, and red blood cells were removed via lysis using an ammonium chloride solution (Stem Cell Technologies). To determine CFU-E and BFU-E colony counts, bone marrow cells were cultured in semi-solid media (MethoCult M3334 for CFU-Es or MethoCult SF M3436 for BFU-Es). Numbers of colonies were counted at 24-48 hours post seeding for CFU-Es and 7 days post seeding for BFU-Es. To determine populations of erythroid precursor cells, flow cytometry was performed. Briefly, isolated bone marrow cells were stained with antibodies for TER119 (PE) and CD71 (FITC). Live cells were determined by staining with DAPI. The different erythroid populations were defined as follows: ProE: Ter119dim, CD71+; EryA: Ter119+, CD71+, large cells; EryB: Ter119+, CD71+, small cells; EryC: Ter119+, CD71−, small cells. Results are shown in FIGS. 20A-20F. A single administration of ActRIIA/B-mFc resulted in increased BFU-E colonies (FIG. 20A), decreased ProE (FIG. 20C) and increased EryA, EryB and EryC (FIGS. 20D-20F) precursor populations at day 14, supporting an effect of ActRIIA/B-mFc on increasing early-stage erythroid progenitor cells and promoting their progression through the erythropoiesis pathway. *p<0.05, **p<0.01, ***p<0.001, ****p<0.0001 by Student's t-test. Error bars are ±SEM.

Example 12—Effect of ActRIIA/B-Fc in a Mouse Model of a Myelodysplastic Syndrome

Transgenic NUP98/HOXD13 mice were rederived at Jackson Laboratories and aged to six months before being separated into groups receiving either vehicle or ActRIIA/B-mFc intraperitoneally at a dose of 7.5 mg/kg twice weekly. As a healthy comparison, age-matched C57Bl/6 wild type mice were acquired from Jackson Laboratories and dosed with vehicle. To quantify changes in hematology, blood was sampled at baseline (day 0), day 19 and day 39. Peripheral blood was collected by cheek bleed, aliquoted into EDTA tubes and stored at 4° C. until analysis at IDEXX BioAnalytics. Statistical analysis was performed by repeat measures two-way ANOVA. Individual comparisons were calculated with a Sidak post test and shown as *p<0.05, **p<0.01. P values are given for the overall significance between treatments. Data are shown as the mean±SEM. As shown in FIG. 21 , ActRIIA/B-mFc increased RBC number, hemoglobin, and hematocrit in the mouse model of a myelodysplastic syndrome, reversing disease-associated anemia.

Example 13—Effect of ActRIIA/B-Fc in a Model of Acute Blood Loss-Induced Anemia

Acute blood loss anemia can occur in multiple clinical settings, including surgery, gastro-intestinal bleeding, and physical trauma. Acute blood loss was induced in Sprague Dawley male rats with jugular vein cannulas (Charles River) 24 hr prior to first dose by removing 20% of blood volume by body weight. Baseline hematological parameters were measured prior to the bleed on Day −1. Rats were treated with ActRIIA/B-mFc 10 mg/kg (subcutaneous injection) at day 0. Every 24 hours at the indicated time points, blood was drawn from the cannula (after the cannula was washed), aliquoted into EDTA tubes, and stored at 4° C. until analysis of hematological parameters at IDEXX BioAnalytics. N=4 (Vehicle), N=5 (ActRIIA/B-mFc). Statistical analysis performed by repeat measures two-way ANOVA. Individual comparisons were calculated with a Sidak post test and shown as *p<0.05, **p<0.01. P values are given for the overall significance between treatments. Data are shown as the mean±SEM. As shown in FIGS. 22A-22C, ActRIIA/B-mFc robustly enhanced recovery from acute blood loss induced anemia. Vehicle treated rats displayed a gradual return toward baseline over the 6-day period, while ActRIIA/B-mFc administration caused a return to baseline within 48 hrs.

Example 14—Effect of ActRIIA/B-Fc on Platelets

In a first experiment, acute blood loss was induced in six-week-old Sprague Dawley male rats (Charles River) 24 hr prior to first dose by removing 20% of blood volume by weight and replacing it with PBS from an arterial catheter. Baseline platelet levels were measured prior to the bleed and before the first dose. At the indicated time points, blood was drawn from the cannula (after the cannula was washed), aliquoted into EDTA tubes and stored at 4° C. until platelet analysis at IDEXX BioAnalytics. Rats were dosed subcutaneously with 10 mg/kg ActRIIA/B-mFc or vehicle every 4 days (3 doses in total), and hematological analysis was performed every 3 days by drawing blood from the cannula. N=5. Two-way ANOVA was used for statistical analysis. *p<0.05 for ActRIIA/B-mFc-treated Day 3 compared to ActRIIA/B-mFc-treated Day 0. Error bars are ±SEM. As shown in FIG. 23 , ActRIIA/B-mFc increased platelets after phlebotomy in rats.

In a second experiment, eight-week-old, female C57Bl/6 (Taconic Biosciences) mice were dosed intraperitoneally with vehicle or 7.5 mg/kg of ActRIIA/B-hFc. Mice were left in home cages and given ad libitum access to water and food. Four days post dosing, mice were bled via check bleeds and approximately 50 μI of blood collected in an EDTA sample tube. Blood was then analyzed with the use of a veterinary hematology analyzer (Heska, HT5). N=10. ****=P<0.0001 by Student's t-test. Error bars are ±SEM. As shown in FIG. 24 , ActRIIA/B-mFc increased circulating platelets in wild-type mice.

Example 15—Acute and Long Term Effects of a Single Dose of ActRIIA/B-mFc on Platelets

To assess the effect of ActRIIA/B-mFc on platelet volume, 10-14-week-old wild type male C57Bl/6 mice were enrolled in the study. Each mouse was injected, once, with vehicle or ActRIIA/B-mFc at 10 mg/kg via IP injection. Blood was sampled 24 hours (N=6 per group), 37 days (N=10 per group), and 51 days (N=10 per group) post-dose, as a terminal procedure from the submandibular vein in restrained conscious mice. EDTA was used as an anticoagulant and blood analyzed to determine platelet count using a Heska HT5 veterinary blood analyzer. As shown in FIG. 25 , a single dose of ActRIIA/B-mFc led to increased platelet volume at 24 hours, 37 days, and 51 days post-dose. Data are shown as average±SEM. Statistics are shown in comparison to vehicle treatment using an unpaired t-test. *P<0.05 and ***P<0.001.

Example 16—Treatment of Thrombocytopenia by Administration of an Extracellular ActRIIA Variant

According to the methods disclosed herein, a physician of skill in the art can treat a subject, such as a human patient, having thrombocytopenia (e.g., thrombocytopenia associated with a myelodysplastic syndrome or myelofibrosis) so as to increase platelet levels (e.g., increase platelet count), increase platelet production, and/or increase megakaryocyte differentiation and/or maturation. The method of treatment can include diagnosing or identifying a subject as a candidate for treatment based on a blood test measuring platelet levels (e.g., platelet count). To treat the subject, a physician of kill in the art can administer to the subject a composition containing an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)). The composition containing the extracellular ActRIIA variant may be administered to the subject, for example, by parenteral injection (e.g., intravenous or subcutaneous injection) to treat thrombocytopenia. The extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) is administered in a therapeutically effective amount, such as from 0.01 to 500 mg/kg (e.g., 0.01, 0.1, 0.2, 0.3, 0.4, 0.5, 0.75, 1, 1.25, 1.5, 1.75, 2, 2.25, 2.5, 2.75, 3, 3.25, 3.5, 3.75, 4, 4.25, 4.5, 4.75, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 100, 150, 200, 250, 300, 350, 400, 450, or 500 mg/kg). In some embodiments, the extracellular ActRIIA variant is administered bimonthly, once a month, once every four weeks, once every two weeks, or at least once a week or more (e.g., 1, 2, 3, 4, 5, 6, or 7 times a week or more). The extracellular ActRIIA variant is administered in an amount sufficient to increase platelet levels (e.g., increase platelet count), increase platelet production, and/or increase megakaryocyte differentiation and/or maturation.

Following administration of the composition to a patient, a practitioner of skill in the art can monitor the patient's improvement in response to the therapy by a variety of methods. For example, a physician can monitor the patient's platelet count using a blood test. A finding that the patient's platelet levels are increased (e.g., a finding of an increased platelet count) following administration of the composition compared to test results prior to administration of the composition indicates that the patient is responding favorably to the treatment. Subsequent doses can be determined and administered as needed.

Example 17—Treatment of Neutropenia by Administration of an Extracellular ActRIIA Variant

According to the methods disclosed herein, a physician of skill in the art can treat a subject, such as a human patient, having neutropenia (e.g., neutropenia associated with a myelodysplastic syndrome or myelofibrosis) so as to increase neutrophil levels (e.g., increase neutrophil count), increase neutrophil production, and/or increase the differentiation and/or maturation of progenitor cells (e.g., myeloid progenitors, myeloblasts, or myelocytes) into neutrophils. The method of treatment can include diagnosing or identifying a subject as a candidate for treatment based on a blood test measuring neutrophil levels (e.g., neutrophil count). To treat the subject, a physician of kill in the art can administer to the subject a composition containing an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)). The composition containing the extracellular ActRIIA variant may be administered to the subject, for example, by parenteral injection (e.g., intravenous or subcutaneous injection) to treat neutropenia. The extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) is administered in a therapeutically effective amount, such as from 0.01 to 500 mg/kg (e.g., 0.01, 0.1, 0.2, 0.3, 0.4, 0.5, 0.75, 1, 1.25, 1.5, 1.75, 2, 2.25, 2.5, 2.75, 3, 3.25, 3.5, 3.75, 4, 4.25, 4.5, 4.75, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 100, 150, 200, 250, 300, 350, 400, 450, or 500 mg/kg). In some embodiments, the extracellular ActRIIA variant is administered bimonthly, once a month, once every four weeks, once every two weeks, or at least once a week or more (e.g., 1, 2, 3, 4, 5, 6, or 7 times a week or more). The extracellular ActRIIA variant is administered in an amount sufficient to increase neutrophil levels (e.g., increase neutrophil count), increase neutrophil production, and/or increase the differentiation and/or maturation of progenitor cells (e.g., myeloid progenitors, myeloblasts, or myelocytes) into neutrophils.

Following administration of the composition to a patient, a practitioner of skill in the art can monitor the patient's improvement in response to the therapy by a variety of methods. For example, a physician can monitor the patient's neutrophil count using a blood test. A finding that the patient's neutrophil levels are increased (e.g., a finding of an increased neutrophil count) following administration of the composition compared to test results prior to administration of the composition indicates that the patient is responding favorably to the treatment. Subsequent doses can be determined and administered as needed.

Example 18—Treatment of Myelofibrosis by Administration of an Extracellular ActRIIA Variant

According to the methods disclosed herein, a physician of skill in the art can treat a subject, such as a human patient, having myelofibrosis so as to increase red blood cell count, increase hemoglobin levels, increase hematocrit, increase the maturation and/or differentiation of erythroid progenitors, increase late-stage erythroid precursor maturation, increase the number of early-stage erythroid precursors and/or progenitors, promote the progression of erythroid precursors and/or progenitors through erythropoiesis, or recruit early-stage progenitors into the erythroid lineage. The method of treatment can include diagnosing or identifying a subject as a candidate for treatment based on a blood test measuring red blood cell count, optionally alongside an imaging test (e.g., an X-ray or MRI) or bone marrow biopsy. To treat the subject, a physician of kill in the art can administer to the subject a composition containing an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)). The composition containing the extracellular ActRIIA variant may be administered to the subject, for example, by parenteral injection (e.g., intravenous or subcutaneous injection) to treat myelofibrosis. The extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) is administered in a therapeutically effective amount, such as from 0.01 to 500 mg/kg (e.g., 0.01, 0.1, 0.2, 0.3, 0.4, 0.5, 0.75, 1, 1.25, 1.5, 1.75, 2, 2.25, 2.5, 2.75, 3, 3.25, 3.5, 3.75, 4, 4.25, 4.5, 4.75, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 100, 150, 200, 250, 300, 350, 400, 450, or 500 mg/kg). In some embodiments, the extracellular ActRIIA variant is administered bimonthly, once a month, once every four weeks, once every two weeks, or at least once a week or more (e.g., 1, 2, 3, 4, 5, 6, or 7 times a week or more). The extracellular ActRIIA variant is administered in an amount sufficient to increase red blood cell count, increase hemoglobin levels, increase hematocrit, increase the maturation and/or differentiation of erythroid progenitors, increase late-stage erythroid precursor maturation, increase the number of early-stage erythroid precursors and/or progenitors, promote the progression of erythroid precursors and/or progenitors through erythropoiesis, or recruit early-stage progenitors into the erythroid lineage.

Following administration of the composition to a patient, a practitioner of skill in the art can monitor the patient's improvement in response to the therapy by a variety of methods. For example, a physician can monitor the patient's red blood cell count, hemoglobin levels, and hematocrit using a blood test. A finding that the patient's red blood cell count, hemoglobin levels, and/or hematocrit are increased following administration of the composition compared to test results prior to administration of the composition indicates that the patient is responding favorably to the treatment. Subsequent doses can be determined and administered as needed.

Example 19—Treatment of Neuromuscular Disease by Administration of an Extracellular ActRIIA Variant

According to the methods disclosed herein, a physician of skill in the art can treat a subject, such as a human patient, having a neuromuscular disease (e.g., SMA, CMT, myasthenia gravis, or congenital muscular dystrophy) so as to reduce muscle atrophy or weakness, increase muscle mass, increase lean mass, and/or maintain or improve muscle strength. The method of treatment can include diagnosing or identifying a subject as a candidate for treatment based on standard clinical tests for muscle diseases (e.g., blood test, muscle biopsy, genetic test, and/or electromyogram). To treat the subject, a physician of skill in the art can administer to the subject a composition containing an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)). The composition containing the extracellular ActRIIA variant may be administered to the subject, for example, by parenteral injection (e.g., intravenous or subcutaneous injection) or by local administration (e.g., injection into the muscle) to treat neuromuscular disease. The extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) is administered in a therapeutically effective amount, such as from 0.01 to 500 mg/kg (e.g., 0.01, 0.1, 0.2, 0.3, 0.4, 0.5, 0.75, 1, 1.25, 1.5, 1.75, 2, 2.25, 2.5, 2.75, 3, 3.25, 3.5, 3.75, 4, 4.25, 4.5, 4.75, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 100, 150, 200, 250, 300, 350, 400, 450, or 500 mg/kg). In some embodiments, the extracellular ActRIIA variant is administered bimonthly, once a month, once every four weeks, once every two weeks, or at least once a week or more (e.g., 1, 2, 3, 4, 5, 6, or 7 times a week or more). The extracellular ActRIIA variant is administered in an amount sufficient to reduce muscle atrophy or weakness, increase muscle mass or lean mass, or maintain or improve muscle strength.

Following administration of the composition to a patient, a practitioner of skill in the art can monitor the patient's improvement in response to the therapy by a variety of methods. For example, a physician can monitor the patient's muscle mass, lean mass, muscle strength, and motor function. A finding that the patient exhibits increased muscle mass or lean mass or maintains or improves muscle strength following administration of the composition compared to test results prior to administration of the composition indicates that the patient is responding favorably to the treatment. Subsequent doses can be determined and administered as needed.

Example 20—Treatment of Osteogenesis Imperfecta by Administration of an Extracellular ActRIIA Variant

According to the methods disclosed herein, a physician of skill in the art can treat a subject, such as a human patient, having osteogenesis imperfecta so as to increase bone mineral density, increase bone formation, reduce bone loss, or reduce the risk or occurrence of bone fracture. The method of treatment can include diagnosing or identifying a subject as a candidate for treatment based on family history, clinical presentation (e.g., frequent fractures, short stature, blue sclera, and/or hearing loss), X-ray visualization of fractures, or genetic testing. To treat the subject, a physician of skill in the art can administer to the subject a composition containing an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)). The composition containing the extracellular ActRIIA variant may be administered to the subject, for example, by parenteral injection (e.g., intravenous or subcutaneous injection) to treat osteogenesis imperfecta. The extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) is administered in a therapeutically effective amount, such as from 0.01 to 500 mg/kg (e.g., 0.01, 0.1, 0.2, 0.3, 0.4, 0.5, 0.75, 1, 1.25, 1.5, 1.75, 2, 2.25, 2.5, 2.75, 3, 3.25, 3.5, 3.75, 4, 4.25, 4.5, 4.75, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 100, 150, 200, 250, 300, 350, 400, 450, or 500 mg/kg). In some embodiments, the extracellular ActRIIA variant is administered bimonthly, once a month, once every four weeks, once every two weeks, or at least once a week or more (e.g., 1, 2, 3, 4, 5, 6, or 7 times a week or more). The extracellular ActRIIA variant is administered in an amount sufficient to increase bone mineral density, increase bone formation, reduce bone loss, or reduce the risk or occurrence of bone fracture.

Following administration of the composition to a patient, a practitioner of skill in the art can monitor the patient's improvement in response to the therapy by a variety of methods. For example, a physician can monitor the patient's bone mineral density by performing dual X-ray absorptiometry or the patient's occurrence of bone fractures based on self-reporting or X-ray imaging. A finding that the patient exhibits increased bone mineral density, increased bone formation, reduced bone loss, or a reduced risk or occurrence of bone fracture following administration of the composition compared to test results prior to administration of the composition indicates that the patient is responding favorably to the treatment. Subsequent doses can be determined and administered as needed.

Example 21—Treatment of Anemia Associated with a Myelodysplastic Syndrome by Administration of an Extracellular ActRIIA Variant

According to the methods disclosed herein, a physician of skill in the art can treat a subject, such as a human patient, having a myelodysplastic syndrome (e.g., anemia due to a low, very low, or intermediate risk myelodysplastic syndrome) so as to increase red blood cell count, increase hemoglobin levels, increase hematocrit, increase the maturation and/or differentiation of erythroid progenitors increase late-stage erythroid precursor maturation, increase the number of early-stage erythroid precursors and/or progenitors, promote the progression of erythroid precursors and/or progenitors through erythropoiesis, or recruit early-stage progenitors into the erythroid lineage. The method of treatment can include diagnosing or identifying a subject as a candidate for treatment using the IPSS-R. To treat the subject, a physician of kill in the art can administer to the subject a composition containing an extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)). The composition containing the extracellular ActRIIA variant may be administered to the subject, for example, by parenteral injection (e.g., intravenous or subcutaneous injection) to treat the myelodysplastic syndrome (e.g., anemia associated with the myelodysplastic syndrome). The extracellular ActRIIA variant (e.g., an extracellular ActRIIA variant having the sequence of any one of SEQ ID NOs: 1-72 (e.g., SEQ ID NOs: 6-72)) is administered in a therapeutically effective amount, such as from 0.01 to 500 mg/kg (e.g., 0.01, 0.1, 0.2, 0.3, 0.4, 0.5, 0.75, 1, 1.25, 1.5, 1.75, 2, 2.25, 2.5, 2.75, 3, 3.25, 3.5, 3.75, 4, 4.25, 4.5, 4.75, 5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 100, 150, 200, 250, 300, 350, 400, 450, or 500 mg/kg). In some embodiments, the extracellular ActRIIA variant is administered bimonthly, once a month, once every four weeks, once every two weeks, or at least once a week or more (e.g., 1, 2, 3, 4, 5, 6, or 7 times a week or more). The extracellular ActRIIA variant is administered in an amount sufficient to increase red blood cell count, increase hemoglobin levels, increase hematocrit, increase the maturation and/or differentiation of erythroid progenitors, increase late-stage erythroid precursor maturation, increase the number of early-stage erythroid precursors and/or progenitors, promote the progression of erythroid precursors and/or progenitors through erythropoiesis, or recruit early-stage progenitors into the erythroid lineage.

Following administration of the composition to a patient, a practitioner of skill in the art can monitor the patient's improvement in response to the therapy by a variety of methods. For example, a physician can monitor the patient's red blood cell count, hemoglobin levels, and hematocrit using a blood test. A finding that the patient's red blood cell count, hemoglobin levels, and/or hematocrit are increased following administration of the composition compared to test results prior to administration of the composition indicates that the patient is responding favorably to the treatment. Subsequent doses can be determined and administered as needed.

OTHER EMBODIMENTS

While the invention has been described in connection with specific embodiments thereof, it will be understood that it is capable of further modifications and this application is intended to cover any variations, uses, or adaptations of the invention following, in general, the principles of the invention and including such departures from the present disclosure come within known or customary practice within the art to which the invention pertains and may be applied to the essential features hereinbefore set forth.

All publications, patents, and patent applications are herein incorporated by reference in their entirety to the same extent as if each individual publication, patent or patent application was specifically and individually indicated to be incorporated by reference in its entirety.

Other embodiments are within the following claims. 

1-6. (canceled)
 7. A method of treating a subject having or at risk of developing thrombocytopenia, comprising administering to the subject a therapeutically effective amount of a polypeptide comprising an extracellular activin receptor type IIa (ActRIIa) variant, the variant having a sequence of (SEQ ID NO: 1) GAILGRSETQECLX₁X₂NANWX₃X₄X₅X₆TNQTGVEX₇CX₈GX₉X₁₀X₁₁ X₁₂X₁₃X₁₄HCX₁₅ATWX₁₆NISGSIEIVX₁₇X₁₈GCX₁₉X₂₀X₂₁DX₂₂ NCYDRTDCVEX₂₃X₂₄X₂₅X₂₆PX₂₇VYFCCCEGNMCNEKFSYFPEMEVT  QPTS,

wherein X₁ is F or Y; X₂ is F or Y; X₃ is E or A; X₄ is K or L; X₅ is D or E; X₆ is R or A; X₇ is P or R; X₈ is Y or E; X₉ is D or E; X₁₀ is K or Q; X₁₁ is D or A; X₁₂ is K or A; X₁₃ is R or A; X₁₄ is R or L; X₁₅ is F or Y; X₁₆ is K, R, or A; X₁₇ is K, A, Y, F, or I; X₁₈ is Q or K; X₁₉ is W or A; X₂₀ is L or A; X₂₁ is D, K, R, A, F, G, M, N, or I; X₂₂ is I, F, or A; X₂₃ is K or T; X₂₄ is K or E; X₂₅ is D or E; X₂₆ is S or N; and X₂₇ is E or Q, and wherein the variant has at least one amino acid substitution relative to a wild-type extracellular ActRIIa having the sequence of SEQ ID NO: 73 or an extracellular ActRIIa having any one of the sequences of SEQ ID NOs: 76-96. 8-10. (canceled)
 11. The method of claim 7, wherein: (a) the thrombocytopenia is associated with a bone marrow defect, a myelodysplastic syndrome, bone marrow transplantation, myelofibrosis, myelofibrosis treatment, ineffective hematopoiesis, Gaucher disease, aplastic anemia, Fanconi anemia, Diamond Blackfan anemia, Shwachman Diamond syndrome, heavy alcohol consumption, cirrhosis of the liver, cancer, an autoimmune disease, a viral infection, a bacterial infection, an enlarged spleen, a vitamin deficiency, cancer treatment, thrombotic thrombocytopenic purpura, idiopathic thrombocytopenic purpura, disseminated intravascular coagulation, hemolytic uremic syndrome, paroxysmal nocturnal hemoglobinuria, a reduction of platelets caused by medication, a dilution of platelets caused by a blood transfusion, hematopoietic stem cell transplantation, acquired amegakaryocytic thrombocytopenia, Pearson syndrome, dyskeratosis congenita, or contraindication to transfusion; (b) the thrombocytopenia is familial thrombocytopenia; or (c) the thrombocytopenia is immune thrombocytopenia. 12-26. (canceled)
 27. A method of treating a subject having or at risk of developing neutropenia, comprising administering to the subject a therapeutically effective amount of a polypeptide comprising an extracellular activin receptor type IIa (ActRIIa) variant, the variant having a sequence of (SEQ ID NO: 1) GAILGRSETQECLX₁X₂NANWX₃X₄X₅X₆TNQTGVEX₇CX₈GX₉X₁₀X₁₁ X₁₂X₁₃X₁₄HCX₁₅ATWX₁₆NISGSIEIVX₁₇X₁₈GCX₁₉X₂₀X₂₁DX₂₂  NCYDRTDCVEX₂₃X₂₄X₂₅X₂₆PX₂₇VYFCCCEGNMCNEKFSYFPEMEVT QPTS,

wherein X₁ is F or Y; X₂ is F or Y; X₃ is E or A; X₄ is K or L; X₅ is D or E; X₆ is R or A; X₇ is P or R; X₈ is Y or E; X₉ is D or E; X₁₀ is K or Q; X₁₁ is D or A; X₁₂ is K or A; X₁₃ is R or A; X₁₄ is R or L; X₁₅ is F or Y; X₁₆ is K, R, or A; X₁₇ is K, A, Y, F, or I; X₁₈ is Q or K; X₁₉ is W or A; X₂₀ is L or A; X₂₁ is D, K, R, A, F, G, M, N, or I; X₂₂ is I, F, or A; X₂₃ is K or T; X₂₄ is K or E; X₂₅ is D or E; X₂₆ is S or N; and X₂₇ is E or Q, and wherein the variant has at least one amino acid substitution relative to a wild-type extracellular ActRIIa having the sequence of SEQ ID NO: 73 or an extracellular ActRIIa having any one of the sequences of SEQ ID NOs: 76-96.
 28. The method of claim 27, wherein: (a) the neutropenia is associated with a bone marrow defect, a myelodysplastic syndrome, bone marrow transplantation, myelofibrosis, ineffective hematopoiesis, aplastic anemia, Fanconi anemia, Diamond Blackfan anemia, Shwachman Diamond syndrome, paroxysmal nocturnal hemoglobinuria, cancer, a vitamin deficiency, an enlarged spleen, an autoimmune disease, a viral infection, a bacterial infection, cancer treatment, a reduction in neutrophils caused by medication, inflammation, hematopoietic stem cell transplantation, Pearson syndrome, dyskeratosis congenita, or contraindication to transfusion; (b) the neutropenia is chronic idiopathic neutropenia; or (c) the neutropenia is familial neutropenia. 29-50. (canceled)
 51. A method of treating a subject having congenital dyserythropoietic anemia, congenital sideroblastic anemia, anemia associated with myelofibrosis treatment, anemia associated with Pearson syndrome, or anemia associated with dyskeratosis congenita, comprising administering to the subject a therapeutically effective amount of a polypeptide comprising an extracellular activin receptor type IIa (ActRIIa) variant, the variant having a sequence of (SEQ ID NO: 1) GAILGRSETQECLX₁X₂NANWX₃X₄X₅X₆TNQTGVEX₇CX₈GX₉X₁₀X₁₁ X₁₂X₁₃X₁₄HCX₁₅ATWX₁₆NISGSIEIVX₁₇X₁₈GCX₁₉X₂₀X₂₁DX₂₂  NCYDRTDCVEX₂₃X₂₄X₂₅X₂₆PX₂₇VYFCCCEGNMCNEKFSYFPEMEVT QPTS,

wherein X₁ is F or Y; X₂ is F or Y; X₃ is E or A; X₄ is K or L; X₅ is D or E; X₆ is R or A; X₇ is P or R; X₈ is Y or E; X₉ is D or E; X₁₀ is K or Q; X₁₁ is D or A; X₁₂ is K or A; X₁₃ is R or A; X₁₄ is R or L; X₁₅ is F or Y; X₁₆ is K, R, or A; X₁₇ is K, A, Y, F, or I; X₁₈ is Q or K; X₁₉ is W or A; X₂₀ is L or A; X₂₁ is D, K, R, A, F, G, M, N, or I; X₂₂ is I, F, or A; X₂₃ is K or T; X₂₄ is K or E; X₂₅ is D or E; X₂₆ is S or N; and X₂₇ is E or Q, and wherein the variant has at least one amino acid substitution relative to a wild-type extracellular ActRIIa having the sequence of SEQ ID NO: 73 or an extracellular ActRIIa having any one of the sequences of SEQ ID NOs: 76-96. 52-54. (canceled)
 55. A method of treating a subject having or at risk of developing a myelodysplastic syndrome, comprising administering to the subject a therapeutically effective amount of a polypeptide comprising an extracellular activin receptor type IIa (ActRIIa) variant, the variant having a sequence of (SEQ ID NO: 1) GAILGRSETQECLX₁X₂NANWX₃X₄X₅X₆TNQTGVEX₇CX₈GX₉X₁₀X₁₁ X₁₂X₁₃X₁₄HCX₁₅ATWX₁₆NISGSIEIVX₁₇X₁₈GCX₁₉X₂₀X₂₁DX₂₂  NCYDRTDCVEX₂₃X₂₄X₂₅X₂₆PX₂₇VYFCCCEGNMCNEKFSYFPEMEVT QPTS,

wherein X₁ is F or Y; X₂ is F or Y; X₃ is E or A; X₄ is K or L; X₅ is D or E; X₆ is R or A; X₇ is P or R; X₈ is Y or E; X₉ is D or E; X₁₀ is K or Q; X₁₁ is D or A; X₁₂ is K or A; X₁₃ is R or A; X₁₄ is R or L; X₁₅ is F or Y; X₁₆ is K, R, or A; X₁₇ is K, A, Y, F, or I; X₁₈ is Q or K; X₁₉ is W or A; X₂₀ is L or A; X₂₁ is D, K, R, A, F, G, M, N, or I; X₂₂ is I, F, or A; X₂₃ is K or T; X₂₄ is K or E; X₂₅ is D or E; X₂₆ is S or N; and X₂₇ is E or Q, and wherein the variant has at least one amino acid substitution relative to a wild-type extracellular ActRIIa having the sequence of SEQ ID NO: 73 or an extracellular ActRIIa having any one of the sequences of SEQ ID NOs: 76-96. 56-72. (canceled)
 73. A method of treating a subject having or at risk of developing a neuromuscular disease, disuse atrophy, treatment-related muscle loss or atrophy, hypotonia, muscle loss or atrophy associated with hypoxia, muscle loss or atrophy associated with a burn injury, HIV-related cachexia, cardiac cachexia, cachexia associated with chronic kidney disease, or pulmonary cachexia, comprising administering to the subject a therapeutically effective amount of a polypeptide comprising an extracellular activin receptor type IIa (ActRIIa) variant, the variant having a sequence of (SEQ ID NO: 1) GAILGRSETQECLX₁X₂NANWX₃X₄X₅X₆TNQTGVEX₇CX₈GX₉X₁₀X₁₁ X₁₂X₁₃X₁₄HCX₁₅ATWX₁₆NISGSIEIVX₁₇X₁₈GCX₁₉X₂₀X₂₁DX₂₂  NCYDRTDCVEX₂₃X₂₄X₂₅X₂₆PX₂₇VYFCCCEGNMCNEKFSYFPEMEVT QPTS,

wherein X₁ is F or Y; X₂ is F or Y; X₃ is E or A; X₄ is K or L; X₅ is D or E; X₆ is R or A; X₇ is P or R; X₈ is Y or E; X₉ is D or E; X₁₀ is K or Q; X₁₁ is D or A; X₁₂ is K or A; X₁₃ is R or A; X₁₄ is R or L; X₁₅ is F or Y; X₁₆ is K, R, or A; X₁₇ is K, A, Y, F, or I; X₁₈ is Q or K; X₁₉ is W or A; X₂₀ is L or A; X₂₁ is D, K, R, A, F, G, M, N, or I; X₂₂ is I, F, or A; X₂₃ is K or T; X₂₄ is K or E; X₂₅ is D or E; X₂₆ is S or N; and X₂₇ is E or Q, and wherein the variant has at least one amino acid substitution relative to a wild-type extracellular ActRIIa having the sequence of SEQ ID NO: 73 or an extracellular ActRIIa having any one of the sequences of SEQ ID NOs: 76-96. 74-97. (canceled)
 98. A method of treating a subject having or at risk of developing osteogenesis imperfecta, bone loss associated with bariatric surgery, bone loss associated with androgen or estrogen deprivation therapy, neuromuscular disease-related bone loss, burn-induced bone loss, or anorexia-related bone loss, comprising administering to the subject a therapeutically effective amount of a polypeptide comprising an extracellular activin receptor type IIa (ActRIIa) variant, the variant having a sequence of (SEQ ID NO: 1) GAILGRSETQECLX₁X₂NANWX₃X₄X₅X₆TNQTGVEX₇CX₈GX₉X₁₀X₁₁ X₁₂X₁₃X₁₄HCX₁₅ATWX₁₆NISGSIEIVX₁₇X₁₈GCX₁₉X₂₀X₂₁DX₂₂  NCYDRTDCVEX₂₃X₂₄X₂₅X₂₆PX₂₇VYFCCCEGNMCNEKFSYFPEMEVT QPTS,

wherein X₁ is F or Y; X₂ is F or Y; X₃ is E or A; X₄ is K or L; X₅ is D or E; X₆ is R or A; X₇ is P or R; X₈ is Y or E; X₉ is D or E; X₁₀ is K or Q; X₁₁ is D or A; X₁₂ is K or A; X₁₃ is R or A; X₁₄ is R or L; X₁₅ is F or Y; X₁₆ is K, R, or A; X₁₇ is K, A, Y, F, or I; X₁₈ is Q or K; X₁₉ is W or A; X₂₀ is L or A; X₂₁ is D, K, R, A, F, G, M, N, or I; X₂₂ is I, F, or A; X₂₃ is K or T; X₂₄ is K or E; X₂₅ is D or E; X₂₆ is S or N; and X₂₇ is E or Q, and wherein the variant has at least one amino acid substitution relative to a wild-type extracellular ActRIIa having the sequence of SEQ ID NO: 73 or an extracellular ActRIIa having any one of the sequences of SEQ ID NOs: 76-96. 99-117. (canceled)
 118. A method of treating and/or preventing treatment-related metabolic disease or age-related metabolic disease in a subject, comprising administering to said subject a therapeutically effective amount of a polypeptide comprising an extracellular activin receptor type IIa (ActRIIa) variant, the variant having a sequence of (SEQ ID NO: 1) GAILGRSETQECLX₁X₂NANWX₃X₄X₅X₆TNQTGVEX₇CX₈GX₉X₁₀X₁₁ X₁₂X₁₃X₁₄HCX₁₅ATWX₁₆NISGSIEIVX₁₇X₁₈GCX₁₉X₂₀X₂₁DX₂₂  NCYDRTDCVEX₂₃X₂₄X₂₅X₂₆PX₂₇VYFCCCEGNMCNEKFSYFPEMEVT QPTS,

wherein X₁ is F or Y; X₂ is F or Y; X₃ is E or A; X₄ is K or L; X₅ is D or E; X₆ is R or A; X₇ is P or R; X₈ is Y or E; X₉ is D or E; X₁₀ is K or Q; X₁₁ is D or A; X₁₂ is K or A; X₁₃ is R or A; X₁₄ is R or L; X₁₅ is F or Y; X₁₆ is K, R, or A; X₁₇ is K, A, Y, F, or I; X₁₈ is Q or K; X₁₉ is W or A; X₂₀ is L or A; X₂₁ is D, K, R, A, F, G, M, N, or I; X₂₂ is I, F, or A; X₂₃ is K or T; X₂₄ is K or E; X₂₅ is D or E; X₂₆ is S or N; and X₂₇ is E or Q, and wherein the variant has at least one amino acid substitution relative to a wild-type extracellular ActRIIa having the sequence of SEQ ID NO: 73 or an extracellular ActRIIa having any one of the sequences of SEQ ID NOs: 76-96. 119-145. (canceled) 